Widening the Range of Primary Care Services Through GPwSI

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Widening the Range of Primary Care Services
Through GPwSI
Denis Gizzi Associate Director NatPaCT Denis.Gizzi
_at_nhs.net
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Introduction

• National context
• Organisational context
• Professional context
• Service Context

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NATIONAL CONTEXT
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Policy Drivers

• Delivering the NHS Plan (April 2002)
• Choose Book
• Plurality of services
• 2008 18 week access
• Practice-led commissioning

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To date..

• National Agreed Clinical Frameworks
• Step by Step Guide
• Nurses with Special Interests
• Demand Decision Management Tools
• Planning Templates
• Development of Educational Programmes
• Latest reported figures 1250 UK GPwSI
• Website www.natpact.nhs.uk/special_interests

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10 Clinical Frameworks

• 6. diabetes
• 7. palliative care
• 8. orthopaedics
• 9. dermatology
• 10. neurology

• mental health
• sexual health
• Minor/Inter Surg
• child protection
• emergency care
• Further developments - Genetics

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DoH / RCGP Definition
General practitioners with special interests
supplement their important generalist role by
delivering a high quality, improved access
service to meet the needs of a single PCT or
group of PCTs. They may deliver a clinical
service beyond the normal scope of general
practice, undertake advanced procedures, or
develop services. They will work as partners in a
managed service not under direct supervision,
keeping within their competencies. They do
not offer a full consultant service and will not
replace consultants or interfere with access to
consultants by local general practitioners.
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ORGANISATIONAL CONTEXT
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Developing Interface Services

• Specifically aligned with LDP outcomes policy
  direction
• Adds service capacity patient choice to support
  both primary and secondary care
• Aligns local strategy business planning to core
  targets (e.g. NHS Plan)
• Driven by analysed local patient need

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Widening Range of Primary Care Services System
Reform
Referral Management Protocol Pathway Continuous
Dev Additional Capacity at Interface Knowledge
Management Education
Demand Capacity Decision Management
Plurality of choice for patients Efficient
booking management experience Aligned with
estates developments Priority scoring elective
flows Choice for booked procedures within PC
Patient Choice Booking
Waiting list priorities Fully worked up
referrals Reducing variability of
referrals Reducing follow ups Validation
PCT managed waiting lists
Allows greater commissioning options Well managed
pathways of care Opportunity for HRG
flexibility Productivity benefits
Commissioning Financial Flows
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Key Principles

• Analyse the nature of health care need
• Development is an Integrated Concern
• Design around legitimate patient need (not
  existing systems)
• Maximise harvest Skill, Knowledge, Experience,
  Competence
• Align action plans to KPIs
• Ensure accountability, probity and best value
• Measure outcomes
• Stakeholder consultation
• Strategic success is a people driven competence
• Define objectives and criteria for success early
• Link to Governance (clinical corporate)
• Understand the nature of constraints

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Redesign tools and techniques

• Strategy
• external
• internal creating conditions for success
• culture and technique

• Technique
• capabilities to carry out improvement
• focus on patient needs
• quality improvement
• service redesign
• implementation
• managing performance
• evaluation

• Culture
• people dimensions
• improvement philosophy
• leadership
• education
• training development
• partnership
• teams
• drive out fear

(source adapted from Don Berwick, Frameworks to
Guide Improvement Work, European Forum on
Improvement in Healthcare, 1998)
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Risks Barriers

• Patient Choice Preferred Consultant Option
• Quality Assurance Patient Perspective
• Time to Train Deliver Backfill in Practice
• Protected Intellectual Capital
• Professional Reticence Private Practice
• Not Always a Cost effective Option
• Requirement for ring fenced resources
• Understanding the Performance Agenda

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PROFESSIONAL CONTEXT
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What difference do GPs with Special Interests
make?What are the core functions?
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The GP with Special InterestDual Citizenship
Model
Strategic Role Educator Role
GPwSI clinical role GMS Role
Community of practice
Dual citizenship
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Opportunities for Career Development

• Align career aspirations with National Policy
• Align personal development with national local
  demands need
• Align CPD with PCT STHA strategies for Service
  Development Commissioning
• Supported CPD Protected learning
• Transferability of intermediate specialist
  knowledge
• GPwSI are in demand
• Whole System Service Development Delivery
• Peer Group Education Support
• National Regional Networks
• Strategic Leadership (quality standards nGMS)
• Patient Focussed Primary Care (Patient
  Champion)

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GPwSI Benefits

• The Individual
• Job Enrichment
• Career Development
• Peer Group Support
• Clinical Networking
• Continuous RD
• Leadership Skills
• Patient Focussed
• Remuneration
• Supported Training
• Knowledge Transfer
• Educator Role
• Intermediate Specialist
• System Reformer
• Retain Balance (GMS)
• Policy / Strategy Lead

• Patients/Service Users
• Local (PC) expertise
• Hospital Avoidance
• Convenient Access
• Faster Access Times
• Booked Appointments
• Local Choice
• Controlled Care Pathway
• Streamlined Diagnostics
• Dedicated Time
• Personal care
• Explanations Certainty
• Quality Service
• Efficient Use of Resources
• Links to Secdry Service

• Systems Service
• Demand Management
• Capacity Planning
• Efficient Care Pathways
• Prioritised Sec Care Ref
• Choice Agenda
• Financial flows
• Knowledge Management
• Whole System Care
• Policy (WRS nGMS)
• Access KPIs
• Measurable Outcomes
• (clinical system)
• Collaborative Working
• Recruitment Retention
• Estates Management

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and the big question is
how do we get from here to here?

• Vision
• Mainstream in PC
• Core curriculum
• Responsive to patient need
• Core PCT Planning
• Embedded in NHS Culture
• Aligning need competence
• Access concerns obsolete

• Now
• lots of experience
• Lots of enthusiasm
• Reactive environment
• Career aspirations
• Patient need/demands
• Policy direction
• Changing professions

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Questions to get you started
What is the status of INTF Services Locally?
Does the PCT have a coherent Local strategic
service plan?
Where Are you now?
What is my interest in INTF services?
Can I align my career development with local
need plans?
Are my aspirations aligned with Policy local
planning?
Have I made a decision to develop career
possibly as GPwSI?
What do I want to Achieve?
Have I appraised myself self audited my
portfolio?
What steps actions do I need to Take who can
help?
What are the constraints can I Overcome them
how?
Can I define each action step Responsibilities?
Can I define a timescale For achieving my goals?
What resources are required where do I get them?
What support can I call on Who will provide it?
Critical Links PCT Local Consultants Local
Planning Mechanisms
Supportive Links RCGP Networks PCT / WDC /
TPCT NatPact / MA
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GPwSI Clinical AssistantsDifferentiated Roles?
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BOTH PROVIDE A VALUED IMPORTANT ROLE BUT ARE
NOT THE SAME
Works Autonomously Responsible for Clinical
Gov Works Unsupervised Service Provider
Responsible for Processes Peer Group
Educator Strategic Lead Risk Management Best
Value Outcomes Accreditation Required Business
Case Dev (LDP)
CLINICAL ASSISTANT
Works within Acute Sector Works under
Supervision Governance Arranged Training / CPD
Role? Defined Activity Employed Status Defined
Workload Programmed Decision Management
GPwSI
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GOVERNANACE
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SSDP (LDP, Policy, Action)
Define Core Activities Specification
Prepare Appraise Application with Supporting
Documentation
Service Portfolio Detailed Business Case Detailed
Specification MDT members Roles Facilities
Equipment Governance Arrangements
Personal Portfolio Evidence of Experience Evidence
of Competence Evidence of Qualification Mentorshi
p Arrangements CPD Arrangements Professional
Sponsor
PCT Service Lead
TPCT Service Lead Mentor
Support available from Natpact tools templates
Local Stakeholder Group Pre Accreditation
Committee
Local Stakeholders Commissioners Prof Peer
Group PEC Acute Social Partners Patient Rep
FORMALACCREDIATION PROCESS
External Assessment Panel Deanery Regional
Experts TPCT(s) RCGP
Has Applicant provided sufficient evidence to
meet Criteria for Special Interest Post
NO
YES
TPCT / RCGP / QTD
Feedback Review / Revise / Re-submit
Accredited
Annual Appraisal Re-Validation
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Governance GPwSI models

• The core activities and the competencies required
• The types of patients suitable for the service
  including age range, symptoms, severity, minimum
  caseload/frequency, and reasons for referral
• The facilities that must be present to deliver
  that service
• d) The clinical governance, accountability and
  monitoring arrangements, including links with
  others working in the same clinical area in
  primary care, at PCT level and in acute trusts
•  

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Governance GPwSI models

• Evidence of training for competencies
• Evidence of successful acquisition of these
  competencies
• Induction, support and CPD
• h) Local guidelines
• i) Monitoring and clinical audit arrangements

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What support for professional development?

• Agree a mentoring arrangement with a local
  consultant
• Many GPwSI spend one session a month in a joint
  clinic with the consultant and attend specialty
  audit meetings
• PCT may pay for ongoing training
• Appraisal of GPwSI service should be part of GP
  appraisal (see RCGP QTD)

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Where can I obtain Training?

• Local consultant mentorship essential
• RCGP clinical practice courses
• RCGP accredited modular GPwSI Diplomas (in
  development)
• Clinical Placements
• Supported Learning Sets
• Knowledge Networks via experienced GPwSIs

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Risk Management Components

• Patient confidentiality Caldicott
• Records Reports
• Patient Consent for Treatment
• Robust Complaints Procedure
• Robust Clinical Protocols
• Clear Pathway Management
• Trigger Mechanisms
• MDU Website www.the-mdu.com

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Typical Outcomes

• GPwSI model circa 400 fces per annum
• DNAs typically less than 5
• Patient satisfaction typically around 90
• Onward referral to secondary care less than 10
  (depending on model)
• New to review ratios typically around 3 new to 1
  review
• GPwSI ffce 70-80 discharged back to referrer
• Learning spreads fast between peer group
• More responsive waiting times (circa 2-3 weeks)
• Effect on recruitment

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Patient Perspective

• The care I received was excellent, I felt I had
  as much time as I needed to explain my problems
  and get the advice and care I needed and I only
  had to wait 11 days!
• The service was very professional and
  organised. The question I have however is, why
  has this type of service only just been
  developed, why has it not always been available?

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The Future Choice and Managed Care
Required Diagnostics Contained Managed
Managed Care Pathway
Interface management
Secondary
Self
Primary
Tertiary
Active Case management