New Models of Working

MCP - What Does Primary Care Need to Do?

David Pannell

30 June 2015

How to find us

Suffolk Federation

61 of 65 practices – 580,000 patients

Practices remain independent partnerships

Not for profit Community Interest Company

Portfolio services – 60 staff + turnover £6m

Whose afraid of their hospital?

Diabetes, podiatry, outpatients & education + inpatients

£2.5m per annum

Model1.Patient involvement2.Investment in primary care3.Diabetes Specialist Team in community

Diabetes – Primary care at scale

Primary care’s role

Working at population level – no exception coding!

Manage wider range patients e.g. stable T1s

Managed to deliver outcomes

Monthly data extract

£6.44 per list patient over 5 years

Monthly data extract from all practices

Diabetes IPH -Contract Quality and Performance Management (CQPM) SCORECARD 2014/15INDICATORS Baseline Year 1

TargetApr-14 data

(May meeting)

May-14 data (Jun meeting)

Jun-14 data (Jul

meeting)

Jul-14 data (Aug

meeting)

Aug-14 data (Sep meeting)

Sep-14 data (Oct meeting)

Oct-14 data (Nov

meeting)

Nov-14 data (Dec meeting)

Dec-14 data (Jan meeting)

Jan-15 data (Feb

meeting)

Feb-15 data (Mar meeting)

Mar-15 data (Apr meeting)

40.3% 40.4% 40.6% 40.8% 41.0% 41.1% 41.3% 41.5% 41.6% 41.8% 42.0% 42.1%39.1% 38.2% 37.4% 36.7% 45.3% 46.3% 47.0% 48.2% 50.1% 53.8% 55.2% 60.3%

8.2% 16.3% 24.5% 32.7% 40.9% 49.0% 57.2% 65.4% 73.5% 81.7% 89.9% 98.0%0.0% 0.0% 0.0% 0.0% 6.0% 6.5% 7.1% 5.5% 9.3% 15.1% 17.1% 95.0%

8.2% 16.3% 24.5% 32.7% 40.9% 49.0% 57.2% 65.4% 73.5% 81.7% 89.9% 98.0%0.0% 0.0% 0.0% 0.0% 6.0% 6.5% 7.1% 13.2% 16.4% 27.8% 35.7% 96.0%

>32.3% >32.3% >32.3% >32.3%Not due Not due 16.7% Not due Not due 47.2% Not due Not due 37.1% Not due Not due 37.1%

71.4% 71.5% 71.6% 71.7% 71.8% 71.9% 72.0% 72.1% 72.2% 72.3% 72.4% 72.5%68.9% 69.0% 69.0% 69.4% 69.7% 70.1% 70.4% 69.9% 69.1% 67.9% 69.1% 69.5%

79.1% 79.1% 79.2% 79.3% 79.4% 79.4% 79.5% 79.6% 79.6% 79.7% 79.8% 79.8%76.5% 76.7% 77.0% 77.2% 77.1% 76.9% 76.7% 76.7% 76.8% 76.6% 78.9% 79.1%

78.4% 78.4% 78.4% 78.4% 78.4% 78.4% 78.4% 78.4% 78.4% 78.4% 78.4% 78.4%77.1% 76.3% 76.3% 76.5% 76.0% 75.5% 74.1% 72.5% 72.1% 72.3% 73.1% 74.7%

63.5% 64.1% 64.6% 65.1% 65.7% 66.2% 66.7% 67.2% 67.8% 68.3% 68.8% 69.4%63.0% 63.0% 61.0% 61.0% 67.0% 65.8% 65.0% 66.1% 67.9% 70.4% 70.8% 75.0%

Patient empowerment change from baseline to 6 weeks following XPERT education

32.3% >=32.3%

Increase the number of type 1 Diabetics who have had a foot check. 63.0%

maintain upper

quartile

Increase in the percentage of patients with diabetes in whom the last blood pressure is 140/80 or less.

78.4%

% of newly diagnosed Type 2 patients OFFERED education within 12 months of diagnosis

0.0% >=98%

% of newly diagnosed Type 1 patients OFFERED education within 24 months of diagnosis

0.0% >=98%

patients receiving all 8 care processes (Weight, BP, Smoking status, HbA1c, urinary albumin, serum creatinine, cholesterol, foot examination)

40.1% 2% increase

percentage of patients with diabetes in whom the last IFCC-HbA1c is 64mmol/mol or less[<8% in DCCT values] in the preceeding 15 months

71.3% 1.17% increase or

69th centileIncrease in the percentage of patients with diabetes whose last measured total cholesterol within the previous 15 months is 5mmol/l or less.

79.0% 0.88% increase or

48th centile

10% increase

Note – this data extract is based on the National Diabetes Audit format which is different to QoF

Practice Dashboard

Peer pressure to drive change

2013/14 mean

Individual Practices

2014/15 outcomes

April 2014

March 2015

Number on register 17,470 18,400 +5%

Received all 8 processes

7,00540.1%

11,09560.3%

Newly diagnosed offered structured education

UnclearT1’s 95% & T2’s 96%

HbA1c <=64mmol/mol

11,68766.9%

12,11265.8%

Cholesterol <=5 12,40071.0%

13,65774.2%

BP <=140/80 11,77767.4%

12,93970.3%

Lessons

Clinical leadership and clinical model

Ability to get practice agreement quickly

Peer pressure and money to facilitate change

Be able to monitor progress

Management