Agenda item

Ben Anderson, Director of Public Health, presented the Public Health annual report which focussed on General Practice.  The headlines of the report were highlighted in the following powerpoint presentation:-

 

Why General Practice

“Health inequalities mean that the Rotherham population experiences more ill health earlier in life and that too many of our population are suffering multi-morbidity, or the impact of more than one health condition at once.  This is bad for Rotherham’s people, bad for Rotherham families and bad for Rotherham’s economy.

 

General Practices are uniquely placed within the health system to impact these inequalities in health.  Through their mix of (..) health professionals, and their position within the heart of communities, General Practices are able to support people to stay healthy, to identify risk factors and conditions early when they can be reversed or controlled, and to support the good management of  ill-health reducing the impacts this can have on people’s quality of life and their ability to contribute to their  communities.

 

To achieve all of these goals however General Practice has to maintain a strong focus on quality, and on the outcomes that matter to the communities they serve, and has to be  funded sufficiently to meet those needs, both now and in the future as our local population continues to age”

 

Report Structure

-        Historical long-term condition prevalence (10-years)

-        Future projections in line with a changing population

-        Quality outcome analysis (condition achievement, and achievement range by GP practice)

-        Condition contact and the impact on appointment sufficiency

-        Finance

-        Recommendations

 

Background and Methodology

-        The Rotherham population has increased by about 1,000 people per year from an estimated 259,400 in 2013 to 268,400 in 2022 (+3.5%).  The oldest age groups are the fastest growing mainly those aged 75+

-        All data is extracted from NHS Digital and 20 conditions have been reviewed across 5 groups

-        Trend data has been used to forecast what prevalence may look like over the next 10 years for Rotherham

-        Trend data on a PCN and general practice level is used to show how current prevalence and trends vary across Rotherham

-        Data for quality outcomes (met need, unmet need and not eligible) have been reviewed to determine opportunities for impact

 

Current Demand

-        Data for 2022/23 suggest there are 200,000 diagnosed conditions across the 20 QOF conditions for patients registered to a Rotherham General Practice

-        Top 5 prevalence are:-

Depression (17.9%)

Hypertension (16.6%)

Diabetes (8.5%)

Asthma (7.8%)

Non-diabetic hyperglycaemia (6.6%)

All other conditions have a prevalence less than 5%

 

Projections

-        This is a combination of the projections of the prevalence of conditions and the projected populations for Rotherham

-        Overall 36,900 more people are projected to be living with at least one of the 19 conditions in 2032/33 than they were in 2022/23 (this excludes NDH due to uncertainty in projection estimates)

-        Projections suggest that 16 of the 20 conditions will increase in prevalence by 2033.  The exceptions are:-

Coronary heart disease and peripheral arterial disease which have been positively impacted by falling smoking rates and changing prescription patterns

Chronic kidney disease which has been shown to be impacted by recording issues and not a disease in number of people living with the condition; and rheumatoid arthritis which remains similar in projections

-        The 5 more prevalent conditions now – depression, hypertension, diabetes, asthma and non-diabetic hyperglycaemia will remain the most prevalent conditions with depression projected to reach a prevalence of 26.7%,  non-diabetic hyperglycaemia 18.3%, hypertension 16.9%, diabetes 10.8% and asthma 9.7%

-        The conditions with the largest percentage point increase are non-diabetic hyperglycaemia (11.7%), depression (9.4%), diabetes (2.3%) and asthma (1.9%)

 

Quality Analysis (1)

-        Aligned to the 5 clinical conditions in the ‘Core20Plus5’

-        Based on one or 2 selected measures in line with the NICE guidance

 

Quality Analysis – Largest Range

-        At a practice level, conditions that have the greatest range within the proportion of patients achieving the quality outcome are for heart failure, depression, diabetes, rheumatoid arthritis and cancer

 

Quality Analysis – Lowest Achievement

-        The conditions that have the lowest quality achievement based on the Rotherham average were diabetes (58.5%), depression (59.4%), asthma (62.3%), hypertension <79 (67.2%) and mental health (70.4%)

 

Additional Assessments

-        Across 17 indicators, if every general practice in Rotherham achieved the same value as for the highest practice for that condition in Rotherham, there would be an additional 19,750 people having their condition assessed or additional guidance given.  Please note that this is 17 conditions - 3 conditions are excluded as all practices are at 100%

-        The conditions which could have the greatest additional numbers if the Rotherham highest was met was for asthma, hypertension, diabetes, COPD and non-diabetic hyperglycaemia

 

Appointment Sufficiency

-           We have reviewed available information on diagnostic period, estimated contact if a condition is stable, estimated contact if a condition is poorly controlled, exacerbated or deterioration and best practice management to determine appointment sufficiency in line with the projected prevalence of individual conditions

-           Based on 2022/23 QOF prevalence data, it is estimated that stable management of a condition could result in 377,000 fewer appointments than if poorly managed

 

Is there an association with patient population and health quality outcomes

-        To determine if it is due to difference in patient population that results in changes in outcomes, we have reviewed the relationship between deprivation and quality achievement

-        As deprivation adjusts for income deprivation, employment deprivation, education, skills and training deprivation, crime deprivation, health and disability deprivation, barriers to housing and services, and living environment deprivation, we may expect any additional differences to be as a result of practice variation

-        As there appears to be weak or no association between quality outcome and deprivation, it is suggested there are individual practice differences that may be influencing the quality outcomes

 

Finance

-        In 2015/16 total spend across contractual payments, additional and enhanced services and quality and outcomes framework was £36,036,006 (excluding ARRS and DES)

-        In 2024/25, the spend across all areas above (including PCN DES and ARRS) is £57,246,561 a 58.9% increase from 2015/16

-        Inflation over this time was 33.8%

 

Discussion ensued with the following issues raised/clarified:-

 

·        The current model was not going to meet the future need

 

·        Non-diabetic hyperglycaemia was a growing area

 

·        There was a difference in the ease of diagnosis of conditions to meet the criteria.  For example arterial fibrillation was very easy to diagnose and could be done via a telephone appointment whereas, for diabetes, there were 8 core processes and every one had to be met with some not up to the Doctor to sort out.  Some of that variance needed to be included

 

·        GPs were underfunded.  Although the core contract had increased slightly (57%) it was below inflation.  There had been 12M appointments in Primary Care last year and 1.8M this year (50% increase) wiping out in the increase in funding received

 

·        There were additional roles that went into Primary Care.  When seeing a patient for a review, the GP would look at several conditions at the same time.  If a review with a nurse, it would be an appointment for a specific condition such as diabetes, asthma etc. and was, therefore, less efficient

 

·        The ICB had selected diabetes and respiratory as 2 of its 3 core issues of focus this year

 

·        Primary Care contracts meant GP services and did not include dentists or pharmacies.  NHS England commissioned GPs but delegated the responsibility to the ICB but there were no additional resources.  It was a national mandated contract with no flexibility within it.  There were 28 practices in Rotherham across 70 sites all of which had slightly different ways of working.  The Quality Outcomes Framework was suspended last year and mandated to use all the money for access and appointments

 

·        Every practice was visited at least every 3 years

 

·        Concern that some of the conditions were “medicalised” when in fact it was more than a tablet but a wider system approach that the person needed.  Some of the conditions were not necessarily GP-led

 

·        Top Tips was a portal that could be accessed by GP practices which covered all conditions and provided resources.  However, it was noted that every time you took some out for development opportunities that meant less appointments available for the general public 

 

Resolved:-  (1)  That the rising trend and future projections for demand on General Practice from the long-term conditions analysed in the report and the future models of community long term condition management that will be required to meet need over the coming decade be noted.

 

(2)  That the preventative actions required to stem the rising prevalence of these long-term conditions and avoid unsustainable increases in demand across the health and care system, with a focus on the common risk factors of smoking, diet, obesity, high blood glucose and alcohol consumption, and the networks and partnerships required within  neighbourhoods to maximise the role of non-clinical intervention, be noted.

 

(3)  That the level of variation observed between General Practices in terms of QOF outcome achievement and exception reporting rates relating to both the delivery of care processes and the achievement of treatment targets and consider the opportunities for quality improvement to support improved outcomes for Rotherham be noted.

 

(4)  That the emerging data and digital capabilities to identify the key areas for performance improvement at practice, PCH and Place level and develop approaches to drive quality, aiming to reduce variation and improve outcomes to that achieved by the top 10% of performers for the chosen indicators be used.

 

(5)  That the above inflation overall increase in the funding to General Practices and how this related to the changing demands and the need for a model of care to develop that will meet future needs, making use of the wider set of Primary Care roles, such as additional roles, to ensure they are having the best effect, target local needs,  and tackle inequalities through community management of long-term conditions, be noted.

 

(6)  That the method of measuring and reporting General Practice performance, using local data to move beyond monitoring appointment numbers and QOF outcomes to identify measures that drive quality based on local need and priority outcomes, be noted.

 

(7)  That the roles of the South Yorkshire Primary Care Alliance and Primary Care Networks in developing and monitoring locally relevant quality outcomes in General Practice, targeting resources to tackle inequalities and driving quality improvement be noted.