Dr Junaid Bajwa, General Practitioner, NHS Greenwich CCG
Post on 13-Jul-2015
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About me
• GP, CCG Governing Body Member NHS Greenwich (s)
• Associate in Public Health, NHS Greenwich (s)
• Council Member of the Clinical Senate, London
• NHS Fast Track Executive Programme
• GP Appraiser NHSE
• Programme Director, Greenwich VTS (s)
• Prepare to Lead alumni, NHS London
• Value Based Healthcare Alumni, Harvard Business School
– The majority of >65s have 2+conditions, & the majority of >75s have 3+ conditions
– More people have 2 or more conditions than only have 1
Multimorbidity: LTC
The working lunch…..
Monday Tues Weds Thurs Fri
0800am
0810am
0820am
0830am
0840am
0850am
0900am
0910am
0920am
0930am
0940am
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1000am
1010am
1020am
1030am
1040am
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1120am
1130am
1140am
1150am
1200pm
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1230pm
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1610pm
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1700pm
1710pm
1720pm
1730pm
1740pm
1750pm
1800pm
1810pm
1820pm
1830pm
1840pm
1850pm
1900pm
What about:
QoF/ LES/DES/ CIS/ Additional Services/ Child
Protection/ GSF/ Information Governance/ CQC/ PRG/
Practice Meetings/ KPI’s/ Audit: Research/ Reviewing
Prescribing/ HR issues/ LMC/ Public Health/ CCG
….(+++++++++++)….
Stepping outside the chaos to manage LTC holistically
Proactive, not reactive medicine
• 16 face to face 10 minute appts• Telephone encounters: 5-10• Home visits (2-3)• Referrals: 3 (am)• Review blood tests/Investigations• Post/ Fax/ Email (75-100 letters per day)• 16 face to face 10 minute appts• Referrals: 3 (pm)
“Exhausting”“Demoralising”
“I feel like a wrung-out rag at the end of
consultations”
“If you’re too caring ... you’ll
crack up in a place like this. Our
boundaries lie where they are
because they have to at the moment”
GP’s and Nurses in deprived areas
struggle with LTC’s
Proactive management, not reactive
Long Term Conditions Module
Improving the experience of healthcare for
those with long term conditions
What if we used what we have?
Metrics
• HbA1c
• Cholesterol
• BP
• MRC
• eGFR*
• BMI
• Waist circ
• Audit C score
• PHQ9
• Being Housebound
• No of repeat
• Age >75
• Being a smoker
Long Term Conditions
• Cancer,
• COPD,
• Asthma,
• Diabetes,
• CKD 3,4,5,
• Hypertension,
• Rh Arthritis,
• AF,
• HF,
• Hypertension,
• Mental Health
condition,
• LD,
• Dementia,
• Parkinsons,
• Cirrhosis,
• being on the
GSF,
• Inflammatory
Bowel Disease,
• Stroke/TIA,
• Osteoporosis
What if we used what we have?
Metrics
• HbA1c
• Cholesterol
• BP
• MRC
• eGFR*
• BMI
• Waist circ
• Audit C score
• PHQ9
• Being Housebound
• No of repeat
• Being a smoker
Long Term Conditions
• Cancer,
• COPD,
• Asthma,
• Diabetes,
• CKD 3,4,5,
• Hypertension,
• Rh Arthritis,
• AF,
• HF,
• Hypertension,
• Mental Health
condition,
• LD,
• Dementia,
• Parkinsons,
• Cirrhosis,
• being on the
GSF,
• Inflammatory
Bowel Disease,
• Stroke/TIA,
• Osteoporosis
• Age >75
(Modifiable) (Fixed)
Within the metric….RAG
Metrics
• HbA1c
• Cholesterol
• BP
• MRC
• eGFR*
• BMI
• Waist circ
• Audit C score
• PHQ9
• Being Housebound
• No of repeat
• Age >75
• Being a smoker
RAG: R-2pts / A-1pt / G-0pt
• G (6.5-7.5), A (7.5-8.5); R (>8.5)
• > 4:2: A: 1 pt if above this ratio
• (>150/90; if DM/CKD/CHD >140/90) 1 pt if above
• G: 3,A: 4, R: 5
• G (CKD2 60-89); A (CKD3 30-59); R (CKD4,5 ie < 29)
• A: (Obese**) R (:morbid obesity)
• A: 1 pt if above norm
• R: (>5)
• (last recorded within 3m) R: 15-27; A: 5-14
• A: 1 point
• Repeat medications (>5): A 1 pt if above
• A 1 pt if above 75
• A 1pts
Managing the chaos: Proactive vs Reactive
• Cumulative totals within each of the categories would then allow a 360°review of your registered population
• Could you then establish a set of rules re: appointments; removing the
monthly letters for each review/ reduce waste in the system; offer extended
appointments with a focus on self management- improving the patient
experience
Green Amber Red
Dr appts
(?around bday)
2/yr 3/yr 4/yr
Nurse appts 3/yr 4/yr 5/yr
PDSA: future add ons
• PDSA cycle
• Coding: Number of hospital admissions A(2); R(>3);
• Quantify length of stay in hospital
• QRISK®2 calculates your risk of cardiovascular disease(R >30%) (A>20)
• QDScore® algorithm calculates your risk of Type 2 diabetes.)
• QoL score (would be useful to include this metric- we do not currently
assess this in primary care)
• Looking at social determinants of health: e.g. personal/ household income,
social housing, postcode, use of carers, social isolation
“Not all that can be counted, counts. And not all that counts can be counted.”
-- Albert Einstein
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