Modernisation through PBC in Northern Lincolnshire

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Modernisation through PBC in Northern Lincolnshire

• Lance Gardner MBE
• Joint LTC Director
• Northern Lincolnshire Goole Hospitals Trust
  /North East Lincolnshire PCT

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Where?....
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Close to?..
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How does it feel now?
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Comparisons between the PCTs

• North Lincs
• Pop. 153,000
• 82 GPs
• 7 single handed
• 22 practices
• 4 PMS

• North East Lincs
• Pop. 180,000
• 80 GPs
• 45 single handed
• 34 Practices
• 4 GMS

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North East Lincolnshire

• Many practice boundaries overlap
• No dispensing practices
• All GPs interested in PBC

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North East Lincolnshire PBC

• 3 levels of budget in unified pot
• Prescribing
• Secondary care
• Community nursing
• Looked at working in localities
• Main issues risk sharing
• service planning
• management capacity

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Potential for new provider organisations

• Unscheduled care
• Elective surgery
• Community nursing

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• Nurses dont generate incomethey generate care.
• For which we make no apology!
• Nurse Hathaway from ER

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LONG TERM CONDITIONSNorthern Lincolnshire Our
Aim

• To put individuals in control of their lives
• To improve the Quality of Life for people with
  long term conditions
• Provide services that are responsive rather than
  reactive
• Reduce the number of hospital admissions
• Reduce length of stay when hospital admission
  required
• To work in partnership

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• Not Patient centred care
• but
• Relationship centred care

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• There now needs to be a shift in emphasis from
  one of consumerism to one of participatory
  democracy. The modern relationship between the
  NHS and patients cannot be purely based on
  patients as consumers. Instead it must be based
  on patients as citizens. This should be seen as
  providing an opportunity for the NHS and those
  working in it and not a threat.
• excerpt from S.o.S. IPPR address June 2001

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LONG TERM CONDITIONS Emergency Admissions

• Top 50 patients make up 10 of all emergency
  admissions
• Top 200 patients make up 39 of all emergency
  admissions

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More Detail about the Top 50

• Average 13 admissions each per year
• Spent a total of 2650 days in hospital in 1 year
• Average 3 consultants but some have 9!
• Some not seen by GP for over 4 years
• Many of then waiting for duplicated diagnostic
  tests
• How do we know this?.
• - audit.by hand!!

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Community Wide Records

• Community wide patient record
• Breaks the practice / patient link
• Supports integrated care needs ICPs
• Enables clinical networks (GPSIs)
• Quality data can be entered anywhere
• No duplication of effort
• Care can be delivered anywhere
• Other practices or in the home
• Access (both ways) in AE
• Virtual case conferences simultaneous access
• E-Mail referrals - 70 MOPD can be done this way

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• Its not always the Technology!

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IV Therapy at home

• No IV therapy service at home except paeds
• Over 1000 day cases for IV therapy
• 276 admissions for cellulitis
• But who should provide it?
• - Acute trust outreach
• -community nursing
• -private sector
• An ethical dilemma

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• From
• Passive recipients
• To
• Active Participants

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• 50 of same day calls can be managed by phone
• Video (POTS) works
• Virtual Support
• e.g. drawing up insulin
• COPD

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Virtual Visiting

• Visiting (real) works and reduces
• Mortality rate by 25
• Admission to long term care by 45
• Virtual Visiting
• Probably as good as an adjunct
• Takes much less travel time

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Remote Monitoring

• Reduces admission for
• CHF by 25
• COPD by 20
• Changes the diagnosis in
• 37 of COPD patients

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Congestive Heart Disease

• Study in New York NY 97 98
• Patients with severe CHF
• Daylink monitor
• Daily weighing
• 5 simple Y/N questions if fell outside norm
• POTS to central nurse who followed up
• Kit shipped direct to patient who installed it
• Cordisco et al. Am J Cardiol 199984860

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Congestive Heart Disease

• Control Group
• N 54
• ER visits 11 (22)
• Re-admit X 1 36 (71)
• Re-admit gt2 11 (22)
• Deaths 11 (22)
• Transplants 14 (27)

• Telemonitored Group
• N 30
• ER visits 3 (10)
• Re-admit X 1 13 (43)
• Re-admit gt2 2 (7)
• Deaths 7 (23)
• Transplants 7 (23)

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• There is no such thing as an
• in-appropriate request
• Only an in-appropriate response.

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Commissioning alternatives

• Self care
• Patient directed care pathways
• Individual care pathways
• Individual patient SLAs

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Issues still to be resolved

• IT
• Data
• Professional
• Cost - tariffs
• Managing deficits
• Resources
• Future PCT role

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Leadership is the capacity to translate vision
into reality Warren G Bennis