Smelling the burning platform
Over the last few years our network of 90 practices has begun to feel the impact of an increasing demand versus supply imbalance. Some areas gave off only a faint smell of a burning platform but in others practice teams reported they were running faster to stand still. Our data showed we were heading for a significant increase in demand by 2020 with a 30% decrease in workforce capacity due to our ageing GP and practice nurse workforce. Not enough younger folk are coming through to fill the gap.
Adding fuel to the burning platform was a recognition the consumer environment was changing…and fast. Technology is changing the way we live our lives, offering instant information, advice and access to services. It’s a societal change that every other sector seems to have responded to except health care. And new market entrants are seeing and filling that gap, challenging the traditional model, see babylonhealth.com as an example. We recognised that to be truly consumer-centred, and maintain continuity of care for those who need it, we needed a major rework of an arguably outdated model.
The model in a nutshell
After much exploring around the globe for best outcomes and new thinking we designed the Pinnacle Health Care Home, sensitive to the New Zealand context. The core principles underpinning our model are that a) patient time and experience is valued and respected, b) the working environment provides a sustainable, high level of job satisfaction for the whole workforce and attracts new staff c) that there is added value over and above good, traditional general practice to overall system efficiency.
Patient’s time and experience is valued in a number of ways and measured through patient surveys. We’ve held focus groups to help model evaluation and feedback, specifically with our Maori population, based on the survey responses. We’re currently planning for real time feedback devices to be located in each practice and are starting to establish Patient Participation Groups aligned to the UK model.
Our care model ensures a patient visits the practice only if they choose to, or need to, by offering a choice of consultation modes and interaction with the practice as alternatives to the traditional face-to-face. This includes telephone triage for those needing timely clinical advice or care for an urgent need. An average of 35% of patients requesting same day appointments are cared for safely without their needing to visit the practice, and patient feedback is very positive. This provides better access for those who do need a same day appointment, shifting away from the ‘first come, first served’ mini ED model of general practice. Planned telephone consultations for routine or follow-up care are offered.
The patient portal enables patients to upload their own health information from any device, email their GP or nurse, receive test results, make an appointment and access their medical record via a consumer friendly app.
The model supports a more proactive population management of those with more complex needs to ensure they get the time and the resources they need to achieve optimum outcomes. Our ‘Year of Care’ programme wraps an integrated team of allied health, social care and specialists around the individual and their family, coordinated by the practice team and enabled by longer appointments. An electronic shared care plan that is patient goal centred is available to all providers given access by the patient. This provides the live ‘one source of truth’, cracking a major integration barrier and enabling that greater system efficiency.
Those working in a Health Care Home practice report greater job satisfaction as a result of the more proactive approach, removing the need for double-booking for example. Ensuring the daily template allocates appropriate time for face-to-face care, triage and telephone consultations, time to manage email traffic and time to meet with colleagues during the morning huddle all contribute to an environment that feels less reactive and calmer. The typical work day moves away from a GP in a room all day to increased opportunity for informal team interaction greatly valued by staff through the creation of an ‘offstage’ collegial space for undertaking non-patient facing tasks.
Using the concepts of lean philosophy, a core element of the model is removing waste from all that is done within the practice. Anything that adds no value, or detracts from, patient care, workforce satisfaction or business efficiency is removed.
Model enablers: leadership, funding, workforce and technology
Alongside aligning a new funding model to a new care model, the major enabler, of course, is network and practice leadership. Pinnacle has a coherent narrative and vision for consumers and practices. We fund the equivalent of a GP session a week to create the headspace in busy practices to lead and manage the change. We deliver a bespoke leadership programme for the practice lead GP, practice manager and nurse lead to focus together on delivery of the agreed practice implementation plan. This focuses on the skills required for leading sustainable change and specifically coaching others though change.
Shifting from a model where the ‘GP is the centre of care’ to one where the ‘GP leads a team that cares’ ensures patients see the right professional first and everyone works to ‘top of scope’. We’ve introduced clinical pharmacists, health centre assistants, nurse practitioners and physician associates to widen the access, capability and capacity of primary care. We’ve also introduced the role of the community health worker to support the lifestyle and behavioural change required for those with long term conditions and begun work to reintegrate district nursing back into general practice.
Our model broke our existing patient management system. It was too provider-centric, based on a doctor with a box in the surgery.
We needed a cloud-based, system-agnostic product to facilitate optimum care co-ordination and integration. Crucially, we needed a consumer-friendly interface that empowered patients to use their health record to manage their own health and care electronically. We’ve cracked that technology barrier with a bespoke product.