care closer to home powerpoint.ppt

Implementing care closer to home – Convenient quality care for patients

25 May 2007Botanical Gardens

Birmingham

Updated guidance on PwSI services including new robust governance arrangements for GPs and

Pharmacists with Special Interests.


Introduction

Mark Cooke Chief ExecutiveDudley PCT


Agenda13:00 Introduction

13:10 Implementing Our Health Our Care Our SayDr David Colin-Thomé, National Clinical Director for Primary Care, LTC ,18 weeks & co-lead for urgent care, Department of Health

13:25 The accreditation of GPs and Pharmacists with Special InterestsDr Matt Walsh, Executive Director of Commissioning and Medical Director, Leeds PCT

14:00 Market Place (and tea & coffee)

14:30 GPs with Special Interests – Dermatology & Skin Surgery Dr Julia Schofield, Consultant Dermatologist, West Hertfordshire Hospitals NHS Trust

14:40 Question and answer session

15:40 Chair’s summary

15:45 Close of workshop


Implementing Our Health Our Care Our Say

Dr David Colin-ThoméNational Clinical Director for Primary Care, LTC ,18 weeks and co-lead for urgent careDepartment of Health


Our health, our care, our say – a new direction for community services

Ambition Enabling health, independence and well

being Better access to GP Better access to community services Support for people with longer term needs Care close to home Ensuring reforms put people in control Making sure change happens


More health care in the communityIncreasing % of healthcare provided locally reflecting:

international best practice advances in technology public preference ageing population Wanless review


Keeping it Personal

Build on the best of traditional General Practice Primary Health Care more than general practice …but registered population and 80% of all NHS

clinical consultations 90% of care solely undertaken in primary care Support for self care Care Closer to Home The practice can link the wider public’s health

and bio-clinical care


Infrastructure

Health and social system environment

Decision support tools and clinical information

system (NPfIT)

Community Resources

Delivery System

Disease Management

Case Management

Better outcomes

Prepared and proactive

health and social care

teams

Empowered and informed

patients

SupportedSelf care

Promoting Better Health

Supp

ortin

g

Cre

atin

g

The NHS & Social Care - Long Term Conditions Model


36 pathways, covering common conditions, that have been developed and published in collaboration with the Royal Colleges

Help commissioners transform pathways by removing unnecessary stages in the patient journey and focussing on real quality improvements

Available on the 18 weeks website www.18weeks.nhs.uk Use of these and other pathways will greatly assist in

reducing waits

To improve clinical care - 18 weeks


Other White Paper initiatives Care Closer to Home Demonstration Project

– 30 across England– Range of different models (nurse led, consultant

outreach, GPwSIs) – An evidence base for shifting care and lessons based

on experience

Community Hospitals– £750m capital funding available over 5 years – 14 schemes announced so far (c£100m)– With more to come and not just community hospitals –

community services eg primary care centres, mobile diagnostics, one stop health and social care centres


DH worked with RCGP and developed broad strategic advice for PCTs and GPs, and also a series of detailed clinical guidelines for individual specialites

NatPaCT published practical advice

PCTs now report over 1750 GPwSIs

Frameworks developed for nurses, AHPs, Pharmacists and Community Dentists

-

Practitioners with Special Interests (PwSIs)


Concerns over quality: some developed in isolation without appropriate training, CPD and governance arrangements …especially from secondary care

AOD found: 64% not within national guidelines 45% not been through any accreditation process 14% no experience of working in secondary care 75% did not attend clinical governance meetings

However…


PWSI Principles First and foremost a generalist Must be able to act without direct supervision The level of skill or competence will always exceed

the core competencies of the individual’s normal professional role

A qualification alone will never demonstrate suitability for the role

Accredited PwSIs deliver clinical services directly to patients and it is the personal interaction and clinical relationship between a PwSI and a patient, which makes accreditation necessary


Who can provide care closer to home?

Generalist care provided in community settings

Specialist care provided in community settings

Specialist care provided

in acute settings

Accredited PwSIs:

GPwSI

PhwSI

DwSI

Accredited PwSIs:

GPwSI

PhwSI

DwSI

NHS staff providing

specialist care:

Nurses, AHPs, medical/consultant staff, pharmacists,

healthcare scientists

NHS staff providing

specialist care:

Nurses, AHPs, medical/consultant staff, pharmacists,

healthcare scientists


Clinical engagement and leadership First contact primary care - ‘Keeping it Personal’ Practice based commissioning Generalist and specialists need to work together Consultants have pivotal role in accreditation Secondary care clinicians key role in shaping

redesigned services High levels of oppositional behaviour imply that

confrontation and criticism are valued more than creativity and risk taking


The accreditation of GPs and Pharmacists with Special Interests

Dr Matt WalshExecutive Director of Commissioning and Medical DirectorLeeds PCT


Introduction• Credentials

GP trainer Director of Commissioning, Clinical Governance

lead and Medical Director Developed Bradford GPwSI accreditation process Chair of Bradford & Airedale accreditation panel.


The CommissioningCycle


Assess needs

Review current service

provisionDecide

priorities

Design service

Shape structure of

supply

Manage demand and

ensure appropriate access to

care

Clinical decision making

Managing performance

(quality, performance,

outcomes)

Patient and public

feedback

Strategic planningService redesignManaging demand

Managing performance


Background & ReflectionsPolicy Context

Emerging focus upon shifting care (GP fund-holding, HSC 1996/35, NHS Plan targets, OHOCOS)

Emerging focus upon clinical quality & risk Choice & plurality, PBC & PBR

Impact Variable geographical uptake and distribution of

PwSI initiatives Focus upon reducing outpatient attendances

• Opinion–based specialties Technical interventions

• Endoscopies, cystoscopies• ECG, 24hr BP, anticoagulation


Emerging Concerns

Specific Definition Clinical risks Accreditation Qualification Standards & Quality Service vs Individual

General Local service and pathway coherence in a

competitive environment• PBR and competition on quality• VFM and effectiveness

Supporting patients• Local services• Assumptions about quality• Choice as it relates to PwSIs


What’s this all about?

CPLNHS and proper commissioning– Improving access – Improving quality– Addressing health inequalities– Provider development

Clarifying definitions and rationale Supporting innovation Managing risk & protecting patients


Vision What does good clinical governance look like for

PwSI services? Minimum necessary bureaucracy Not duplicating other regulatory processes Clear responsibilities for:

– PwSI– Commissioners– Providers– Accreditation bodies


Emerging themes

Gate-keeping function of primary care Blurring boundaries between clinicians Focus upon assessment of competencies

required vs those demonstrated Coherent service planning and development Guarding the notion of specialism. Refreshed specialty specific guidance


Key points Core generalist role Receive and manage referrals

– Referral as the trigger point Higher levels of skill

– Specialty specific guidance Independent – ie no direct supervision


New PwSI definition“A GP or a Pharmacist with a Special Interest supplements their core generalist role by delivering an additional high quality service to meet the needs of patients. Working principally in the community, they deliver a clinical service beyond the scope of their core professional role or may undertake advanced interventions not normally undertaken by their peers. They will have demonstrated appropriate skills and competencies to deliver those services without direct supervision. “


The Accreditors Subset of PCT and include, as a minimum:

Senior commissioner Senior professional rep (LMC, PEC, LPC, Lead Pharmacist, GP from RCGP) Lay person Senior clinician

Adhere to set of competencies (Page 9)


Overview

Page 8


Commissioners preliminary role

Page 10

Develop service specification by defining: Patient inclusion criteria Referral arrangements to and from all other services How they communicate and integrate with relevant clinical networks Physical, human, audit and financial resources required to deliver the service Robust and integrated clinical governance arrangements Support required from other health and social care professional and services Evidence of the ways in which local people have been involved in developing

and planning the service A clear definition of the role that the individual GPwSI or PhwSI will play within

the service Arrangements to ensure that the GPwSI or PhwSI understands clearly the

nature of all the services which support the patient pathway, clinical network, and referral system

Arrangements for the GPwSI’s or PhwSI’s ongoing continuing professional development

That appropriate indemnity cover is in place Requirement that there is a properly authorised statement of compliance with

Standards for Better Health


Page 11

Step 1Invite applications from individuals who wish

to be accredited


Page 12

Step 2Verify the skills and competencies of the

individual GPwSI or PhwSI and reach a decision about individual accreditation


Page 13

Step 3Optional service visit to validate the quality of

the provision and the role of the individual GPwSI or PhwSI


Page 14

Step 4Re-accreditation of the individual GPwSI or PhwSI and the service in which they work (at

least every three years)


Local (PCT held) list

g• GPwSI/PhwSI

• Length/dates of accreditation

• Specialty

• Available for public inspection


PCT Directions

NATIONAL HEALTH SERVICE

THE ACCREDITATION OF GENERAL PRACTITIONERS AND PHARMACISTS WITH

SPECIAL INTERESTS DIRECTIONS 2007

The Secretary of State for Health, in exercise of the powers conferred by section 8 of the National Health Service Act 2006(1), gives the following Directions:

Citation, commencement and application

1.—(1) These Directions, which may be cited as the Accreditation of General Practitioners and Pharmacists with Special Interests Directions 2007, shall come into force on 1 June 2007.

(2) These Directions are given to Primary Care Trusts in England and apply in relation to England.

Compliance with guidance document: the accreditation of General Practitioners and Pharmacists with Special Interests

2. A Primary Care Trust shall have regard to the provisions of the guidance document entitled “Implementing care closer to home – Convenient quality care for patients Part 3: The accreditation of GPs and Pharmacists with Special Interests” issued by the Department of Health in April 2007 when—

(a) commissioning any services to be provided by a General Practitioner with Special Interests or by a Pharmacist with Special Interests, or

(b) assessing or accrediting a General Practitioner with Special Interests or a Pharmacist with Special Interests as suitable to provide any services the Primary Care Trust wishes to commission.

Signed by authority of the Secretary of State for Health Jeff Peers A member of the Senior Civil Service Department of Health 17 May 2007

(1) 2006 c.41.

PCTs shall have regard to the provisions set out in Part 3 when commissioning, assessing or accrediting a GP/PhwSI service


Implementation timescales All existing GPwSIs be re-accredited by March 2009

All new GPwSIs and PhwSIs be accredited in accordance with these guidelines.

If the GPwSI or PhwSI’s work is discontinued, or if for any other reason after the commencement of the service the individual is unable to use their enhanced skills for a period longer than twelve months, they should be re-accredited before they work again as a GPwSI or PhwSI.


Market Place(and tea & coffee)

14:00 – 14:30


GPs with Special Interests

Dermatology & Skin Surgery

Dr Julia SchofieldConsultant DermatologistWest Hertfordshire Hospitals NHS Trust

Member PwSI Steering Group and Dermatology GPwSI guidance development group


Dermatology GPwSIs: Background

NHS Plan 2000:

‘..up to 1000 specialist GPs to take referrals from their colleagues for a range of conditions..’

Dermatology one of the specialities identified as suited to the role of GPwSIs


Dermatology GPwSIs: 2003 framework


Dermatology GPwSIs: 2003 framework

THE GOOD NEWS

Action on Dermatology pilots: Reduced waiting times for those

attending clinics

Several sessions needed across a health community to reduce overall access times

Quality of care and patient experience good

Good links with secondary care optimise seamless patient care


Integrated model, works well, robust training and accreditation programme

Big increase in capacity (10 clinics per week) Trivial referrals received initially Reduction in referrals to secondary care Secondary care referrals more appropriate

Threat to secondary care funding?

‘previously unmet demand is now being met and met appropriately..’

Eastern Wakefield PCT: Lessons


Dermatology GPwSIs: ConcernsFollowing audit* against DH framework BAD/PCDS/AoD meeting requested (Feb 2005):

More robust accreditation framework for dermatology

Some standardisation of terms and conditions

Audit, quality and outcome measures

*Schofield JK, Irvine A, Jackson S, Adlard TP, Gunn S, Evans N. General Practitioners with a Special Interest (GPwSI) in Dermatology: results of an audit against Department of Health (DH) guidance. Br J Dermatol 2005; 153 (suppl. 1):0-1


Developed by multidisciplinary working group including reps from BAD, PCDS, SCC, RCGP

Aims to ensure the commissioning of high quality dermatology services


ContentsContents

Service models for dermatology and skin surgery

The support and facilities required The curriculum and core competencies

required Key points to consider Assessment tools Assessment requirements


Possible models of

service delivery

Diagnostic and disease

management service only with no surgery

Community skin cancer service

GPwSI dermatology skin surgery service

(excluding skin cancer)


management service with more advanced

surgery


management with a limited skin surgery

service


Assessment tools


Skin surgery: GPwSIs and PwSIs

Dermatology guidance specifically for GPwSIs

BUT includes standards for all performing skin surgery (PwSIs)

Commissioners advised to use the document when developing skin surgery services

Competencies may be further developed for other PwSIs (PhwSIs)


Specialty Specific Guidance

RCGP co-ordinating refresh through relevant professional bodies

Evidence to support commissioners and accreditors during accreditation process

Competency based

In most cases applicable to all PwSIs

Published throughout 2007


Developing Dermatology GPwSI services Assess need, Part 2 guidance, patient centred

process involving all key players

Define model of care and identify local skills and resources

Accredit the individual once the model of care has been agreed

Be mindful of National Guidance (NICE skin cancer)


Developing Dermatology GPwSI services

Whatever the barriers try and be joined up

Integrated services work best for patients

Think quality, access, patient experience first

Value for money last!!


How do we get there?

DONALD RUMSFELD: There are known knowns. There are things we

know that we know. There are known unknowns. That is to say, there are things that we now know

we don't know. But there are also unknown unknowns. There are things we do not know we

don't know.

http://www.washingtonpost.com/wp-srv/photo/postphotos/orb/style/2005-04-29/4.htm


Question & Answer session

14:40 – 15:40

Panel Members

Dr David Colin-ThoméDr Matt WalshDr Julia Schofield


Close

Contacts for further information

Have a safe journey home..

Beth [email protected]

Phil [email protected]

www.dh.gov.ukwww.primarycarecontracting.nhs.uk

care closer to home powerpoint.ppt

Documents

saydr david

implementing

disease management

primary care

shifting care

tea amp

special interests

direct supervision