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Mutuality, A&E and Mutuality, A&E and Primary CarePrimary Care
Dr Adrian BakerDr Adrian Baker
Clinical Lead Nairn & ArdersierClinical Lead Nairn & Ardersier
Carers & Voluntary
AHP’s / Pharmacy
Nursing
GP’s
Community Hospitals
Secondary / Tertiary Care
99 ?
OR
999
Nairn and Ardersier c1997Nairn and Ardersier c1997
• The service has been in operation since March 1997.• PCEC 250-400 calls to the service each month. • A&E 100 – 300 attendances a month• There is minimal use of protocols, referring instead to
guidelines or a more experienced opinion when necessary. National guidelines are utilised when possible.
• Each nurse uses their own clinical judgement and defines their own level of competence (and doctors respect this).
• The PCEC service is fully integrated with A&E
Localities / Parish ?Localities / Parish ?
If we are honestly going to involve ourcommunities, our patients, the providers and thecurrent political systems then I think we have tolook back to our Scottish roots to give us a firmfoundation on which to build the new ScottishHealth Service. In the Scottish Nation 1700-2000T.M. Devine looked at the old parish model.
CommunityHospital
GP’s Mental Health
Children
Social ServicesCommunity
NursingSupport
HR, IT
Finance
CLINICAL LEADERSHIP
The Extended Primary Care Team in the Locality
Patient
Elected Representaion
Integrated responseIntegrated response
• GP• SAS / Home care alerts / telecare• A&E / PCEC integrated• Nurses for palliative care• Care plans, Alerts, Integrated IT (Vision)• Community Support Team / NHS Home
Care, OOH home care• Patients call single number
PRIMARY
999 Calls: 0.5m New: 2.8mNon Emergency: 1.8m Repeat: 8.5m
Calls: 0.7m
Treatments: 3.5mAdmissions: 0.5m Admissions: 0.2m Discharges: 0.4m
px items: 72.2m
New: 1.4mRepeat: 0.1m
ContactsNew: 7.2mRepeat: 13.1mActivity: 6.3m
Tests: 0.9m OOH: N/A Discharges: 0.7m
New: 24.1kDischarges: 0.6m Deaths: 28k
Hours: 27m
Attendances: 3m
KEYAdmissions: 59.5k Level of contacts
10 - 100 million1 - 10 million
discharges: 49.1k Deaths: 10.6k 100k - 1 million0 - 100kUnknown
COMMUNITY
ACUTE
Self to A&E: 0.9m
Outpatients/Nurse Clinics/AHPsAmbulance Service
NHS24
DentistsEmergency IP Elective IP Day Cases
Pharmacy
A&EAHPN/A
GP Practice
Discharges from HospitalOphthalmics
Discharge
Intermediate CareN/A
Day PatientsResidence Death
Death
Home Care
Day Care
Care Home
HealthIncidents
Self CareNon NHS care (e.g. private)other UK NHS
Transfers0.2m
Out of hours primarycare services ~1m
General PracticeGP and Practice Nurse
contacts: 23.7m
Day careAttendances: 3m
DentistTreatment courses:
3.5m
PharmacyItems: 82m
Community psychiatryteam
Visits: 863k
AHPAttendances: 2.3m
Healthincidents
Ambulance Service999 calls: 0.6mAir Ambulance: 3k
NHS 24Calls: 1.5m
OpthalmicsEye tests: 1.6m
Nurse & health visitorsVisits: 5.6m
Day patientsAttendances: 660k
Home careHours: 34mClients: 69k
Care home - long stayresident weeks: 1.9m
residents: 36k
Community learningdisabilities team
Visits: 85k
A&EAttendances: 1.6m
OutpatientsConsultant clinics 4.4mNurse-led clinics 0.7mAHP clinics 4.5m
Day cases430k
Long stay inpatientsPatient weeks: 361k
Inpatients (discharges)Acute specialities: Emergencies: 528k Elective: 408kOther short-term specialties: 157k
Community midwifeVisits: 412k
PRIMARY & COMMUNITY HOSPITALS
Ambulance (Patient Transport & Car Services)Patient journeys: 1.7 m
Note: the diagram excludes some other services provided in the community
Contacts20m +
10m - 20m5m - 10m1.5m - 5m
0.5m - 1.5munder 0.5m
Scottish Health and Care Activity 2007/08
Care home - respiteadmissions: 35k
Sources: ISD Scotland, SG
Home care£408m*
Out of hours primarycare services £68m*
General Practice£705m
Day care£232m*
Dentist£329m
Pharmacy£1.1bn
Community psychiatryteam
£143m
AHP£116m
Healthincidents
Ambulance Service999 calls: £136mAir Ambulance: £10m
NHS 24£55m
Opthalmics£78m
Nurse & health visitors£229m
Day patients£246m
Care home - long stay£724m*
Community learningdisabilities team
£29m
A&E£148m
OutpatientsConsultant clinics £552mNurse-led clinics £45mAHP clinics £269m
Day cases£317m
Long stay inpatients£696m
InpatientsAcute specialities: £2.1bnOther short-term specialties £470m
Community midwife£33m
PRIMARY & COMMUNITY HOSPITALS
Ambulance (Patient Transport & Car Services)£34m
Note: the diagram excludes some other services provided in the community* These figures refer to 2006/07
Scottish Health and Care Costs 2007/08
Care home - respite£50m*
Sources: ISD Scotland Costs Book; SG LocalFinancial Returns; NHS24; Scottish Government
Costs£1bn +
£500m - £1bn£250m - £500m£100m - £250m£50m - £100m
under £50m
Journey of DependenceJourney of Dependence
• Home Care - £6,000 per case per year(34M hours, 69,000 clients)
• NHS 24 - £36.67 per call• OOH PCEC £68.00• GP in hours contact £30.00• District nurse / Health Visitor £40.89• A&E £92.50• Admission (Ave 10 days) £2,784• 51x and other dispossessed patients• Long stay care £ 20,111 a year
EEA by practice for HighlandEEA by practice for HighlandPractice Elderly Emergency Admission Rates 2003-2005
0
100
200
300
400
500
600
Laggan
Bro
adfo
rdA
risaig
Kin
lochle
ven
Kin
mylie
sP
ortre
eB
alla
chulis
hB
rora
& H
elm
sdale
Gols
pie
Ft W
illiam
(Hig
h S
t)F
t Willia
m (T
weedale
)T
ain
Riv
erv
iew
Pra
ctic
eD
unvegan
Dorn
och
Ferin
donald
Malla
igF
t Willia
m (N
evis
)G
ranto
wn
Lybste
rC
arb
ost
Sale
nC
anis
bay &
Castle
tow
nT
hurs
o, P
rincess S
tLairg
Kyle
Thurs
o (B
MF
S)
Riv
ers
ide
Wic
k M
edic
al C
entre
Bonar B
ridge
Cro
marty
Fairfie
ldA
lness/In
verg
ord
on
South
sid
e R
dC
row
nM
unlo
chy/N
th K
essock
Cullo
den (C
F)
Din
gw
all
Kin
gussie
Kin
gsm
illsA
vie
more
Ard
ers
ier/N
airn
/Cro
yS
courie
Fort A
ugustu
sA
rmadale
/Betty
hill/P
orts
kerry
Burn
field
Nairn
Ard
laric
h (M
W)
Gle
nelg
Beauly
Din
gw
all/S
trath
peffe
rC
ullo
den (M
M)
Dunbeath
Sm
all Is
les
Cairn
s M
edic
al P
ractic
eB
eauly
(Hig
h S
t)T
ain
(GC
M)
Tongue
Lochalin
eD
urn
ess
Fortro
se/A
voch
Aultb
ea &
Gairlo
ch
Ulla
pool
Lochcarro
nLochin
ver
Foyers
Dru
mnadro
chit
Apple
cro
ss
Torrid
on
Ad
mis
sio
ns/1
000 P
op
ula
tio
n
Pyramid to Oil TankerPyramid to Oil Tanker
EEA rates by Locality EEA rates by Locality (>65, >75, >85)(>65, >75, >85)
0.00
100.00
200.00
300.00
400.00
500.00
600.00
700.00
Badenoch &Strathspey
Caithness EastSutherland
Inverness Lochaber Nairn &Ardersier
NWSutherland
Ross &Cromarty
Skye &Lochalsh
Highland
Locality
EE
A / 1
000 P
op
ula
tio
n
>65yrs
>75yrs
>85yrs
Local vs National systemLocal vs National system
• Local nurse talks to patient
• Same number – one point of contact 24/7
• Can See & treat• Local Knowledge -
ALERTS• Can discharge• Can call in extended local
Primary Care Team & Social Services
• Very Close, consistent working with GP’s
• Remote nurse• American Algorithm• 7% UK GDP vs 14% USA• Advice• Or GP• Or A&E• Or Ambulance• Ice cream• High cost (Effective?)• Remote working
Since Opt OutSince Opt Out
• NHS 24 1.5M calls a year
• A&E increase 6% a year
• Cost NHS 24 = £55M = £10 a patient
• Lochaber / Nairn & Ardersier = £150,000
• With a locally based Telephone triage system could this money be put to better use?
(NHS Highland £3.3M)
““If difficult…..If difficult…..
………….Don’t……..Don’t…….
………….Do”.Do”
VisionVision• Equity of funding and service• Local services to ensure local response• Clinically and socially appropriate
response. Mental Health• Ability to stabilise and transfer to
secondary care when necessary• Integration with Social Services