1. Whole System Working Project NHS Forth Valley Stuart Cumming June 2011 Working Better Together

2. Whole Systems Working and Practice Profiles Improving communication & collaboration between primary and secondary care Enabling understanding of wider strategy and system Managing variability - promoting best model practice and improving quality Clinical Engagement Providing comparative activity data in format to enable behavioural change

3. Workstreams Emergency Admissions Discharge Planning Accident and Emergency Referrals Cancer pathways Prescribing

4. Practice work- Examples GPs critically appraise referrals for high variability and volume specialties Referral rationale, quality and alternatives Learning needs System issues Significant Event Analysis of emergency admissions and discharge process

5. Practice work-Prescribing Antimicrobials and HAI Lipid Lowering Polypharmacy Antidepressants

7. Antibacterial Drugs Individual prescribers

8. Practice Profiles

19. Comparative data - Orthopaedic referrals Practice 1 94 referrals (8.59/1,000) 84 outpatients 4 emergencies 8 day cases 22 electives 41% Practice 2 246 referrals (5.86 /1,000) (ave 5.43) 212 outpatients 6 emergencies 26 day cases 20 electives 23.5%

21. Outcomes and Development

22. Outcomes Improved Clinical Engagement/Understanding Improved cross system working and integrated pathway development Communication of primary care issues Acceptance of use of data to understand variability issues Use of evidence to encourage reflection of clinical practice Greater focus on rationale, efficient prescribing Informing future alternative model of care- - ACP, shifting the balance, Right Person, Right Place, Right Time National rollout- QIP QOF

23. Influencing outcomes at the Front Door

24. Emergency admissions issues Mostly unavoidable….but….improvements possible Practice access Case Management Anticipatory Care Planning* Medication reviews/errors* LTC and self management links* Access for advice, fast track, diagnostics* Effective discharge planning* Need for NHS24 locally responsive Need to integrate with OOH better Responsive community services as alternatives System access- A&E should be for A&E only * *Identified for further work

25. Factors influencing A&E Attendance Clinical Issues Alcohol* Mental Health problems -Anxiety* -Severe & enduring -Self harm Drugs Minor Injuries Falls/Trauma/Fractures/RTAs Respiratory Conditions-COPD and asthma* Chest Pain* Seizures Abdominal Pain Anaphylaxis Non- Clinical Issues Culture and expectations- convenience/ease of access/open door* Perception of difficulty accessing GP appointment* Poor coping strategies* 999 and NHS 24 triage A&E review Proximity to A&E General high service users

26. How could we make changes? Triage and divert Challenge, educate, empower patients Better feedback/communication from A&E to practices Recognise capability of primary care Share info effectively across system (Taycare, ECS, ePCS, ACPs) More responsive Local Authority Services Integrated pathways (Falls and Alcohol)

27. Practice Profiles 2011/12 Link to QOF changes & Enhanced Service Review GMS QOF - Quality Improvement and Productivity Reducing Emergency Admission - Ambulatory alternatives to admissions Referrals pathways Prescribing Whole System Working project 2011/12 Falls Pathways Appropriate use of lab and radiology services Polypharmacy Cancer Pathways Increase data accessibility through intranet resource