How can working at scale improve access to services?

The following article has been featured in the Royal College of General Practitioners’ Clinical News email…

How can working at scale improve access to services?

As part of the RCGP Supporting Federations programme, RCGP and the Nuffield Trust created two surveys which were circulated to CCGs and GPs in England which sought to find out more about whether practices are forming at scale organisations, and if so how they are doing this. An interim analysis of responses, undertaken by the Nuffield Trust, has indicated what the top five actions are that federations undertake after forming.

We were interested in finding out how existing federations have achieved these actions; this article explores how Suffolk GP Federation improved access to services for adults with diabetes in North East Essex CCG.

Dr Tim Reed
Founding Chair, Suffolk GP Federation

In 2013 NHS North East Essex CCG commissioned Suffolk GP Federation to provide a community service for adults with diabetes – North East Essex Diabetes Service (NEEDS). The CCG was not prescriptive about the model used and the Key Performance Indicators (KPIs) were clinically meaningful and small in number, including HBA1c, BP and cholesterol as outcome measures and care processes as a process indicator.

Suffolk GP Federation was appointed as the prime contractor which allowed us to subcontract for podiatry services with the community trust, with the hospital for specialist care, and other providers for retinal screening. Being the prime contractor allowed the federation to reshape all these services to be contributory parts of a single coherent whole. The contract is for 5 years with an option for two more at a fixed £2m a year contract, with 25% of contract value linked to performance.

Service redesign is often managerially led and consists largely of structural change or introducing new technology. In this case the hands-off approach of the CCG allowed the GP federation, with its clinically-led and primary care-based approach, to concentrate firstly on designing the clinical model and only then putting the structures in place to support that model. The clinical offer was based on successful services operating elsewhere in the country including Bexley, Tyneside and Tower Hamlets.
Suffolk developed three main arms in the clinical model of care:

• The specialist team was formed of diabetes nurses in hospital and in the community, led by a consultant moving from the hospital to join the team. The hospital clinic was closed and the specialist team’s role is now largely to support practice teams seeing more complex patients, rather than seeing patients themselves. Their role has become supportive and educational and they can also assist practices with data collection and audits. The team also provide specialist inpatient nursing under a sub-contract to Colchester Hospital.
• A Federation Local Enhanced Service (LES) funded by cost savings from closing the hospital clinic enabled the transfer of financial resources from the acute sector into primary care, which funded the increased and more skilled activity. It also incentivised each practice to identify a lead GP and nurse and enabled quarterly meetings to build enthusiasm and share experience, the Year of Care patient centred model discussed below and meetings and joint surgeries with the specialist team. A new clinical dashboard automatically collecting each practice’s outcome data on a monthly basis has generated evidence and peer influence to engage GPs in this new way of working. This data includes all patients with diabetes including those exception coded under QoF.
• Nearly all studies show that increased patient involvement is associated with improved outcomes in long term conditions. Patients are involved on the board running the service and it is planned to include them in service delivery as facilitators, mentors and champions. The LES has been used to incentivise practices to change the traditional six monthly review model to the Year of Care/House of Care model where the first of two closely spaced appointments is by an HCA to carry out the care processes. Patients are then sent their results with an explanatory handbook and invited to set their own goals – which may be non medical – for the following year. The second appointment is then with the practice nurse who has received additional training in patient centred consulting.

The pace of change has been rapid, but at this early stage in the life of the contract not all practices have been able to implement the whole clinical model. The vast majority of practices however have been able to do so and with strikingly positive outcomes so far. They have been ably supported by positive and enthusiastic hospital consultants and community staff. Some outcomes include:

• 20% increase in the patients receiving all eight care processes
• Number of diagnosed patients up 5.3%
• Patients reporting higher levels of engagement
• 31.6% decrease in readmissions
• All outpatients are now managed outside hospital
• GPs have embraced a new way of working with 39 of 42 practices taking up the LES
• Admissions for DKA/hypoglycaemia /hyperglycaemia fell 7%
• HBA1c patients controlled to 64mmol/l down 1.1% (NB – a negative outcome)
• Number of patients with cholesterol < 5 up 3.2%
• Number of patients with BP <  140/80 up 2.9%

Prime contracting is complex but it can provide the ‘leverage’ for aligning multiple providers around a single coherent clinical model for the care of people with diabetes. GP federations are well placed to deliver these services at scale; because they are clinically led they have a much better understanding of the issues and often put the clinical model at the heart of any change, with the structures following on from that. In turn, having a good clinical model is more likely to deliver improved clinical outcomes.

Shifting hospital services into the community requires a collaborative approach from consultant colleagues as well as resources for general practice and support from the specialist team. A logical clinical model, peer pressure and clinically relevant data combined with financial incentives can drive scale change in primary care. Forward-thinking community focussed commissioners developing clinically relevant KPIs were also an essential part of this scheme.

Future plans for the service include:

• Focusing on ‘hard to reach’ patients who do not access traditional routine care including care home residents and young people
• Psychological support for patients finding it hard to change habits or with mental health problems
• Earlier identification of foot complications and reduce amputation rates
• Patient groups supported to develop wellbeing

Please send any comments to: david.pannell@suffolkfed.org.uk.