the nhs five year plan-david panell presentation
TRANSCRIPT
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