Commissioning Primary Care to Improve Health Outcomes

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Commissioning Primary Care to Improve Health
Outcomes

• Dr David Paynton FRCGP, DMS
• Southampton City Primary Care Trust

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National Health Service

• National context
• Local context in Southampton
• Primary care

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NHS Policy and Implementation

• Shift from command and control management to
  rules based system
• Use of managed market as dynamic for change
• Primary Care Trusts local regulator
• Indicative budget for hospital care held by
  practices (Practice Based Commissioning)

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The NHS market Competition or Co-operation

• Procurement, contracting and performance
  management driving improvement
• Implications of EU competition law and
  harmonisation
• New models emerging no single model
• New corporate players

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NHS ten year journey

• Real growth in spend with major reduction in
  waiting times
• Improvements in cancer, cardiac care and
  increase in overall life expectancy
• Secondary care shifting to community and primary
  care solutions
• Strengthen commissioning to support Public Health
  improvements

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Southampton The Context

• Regional City population 250,000
• Working European City within South Hampshire
• Two Universities
• Industrial base
• Large teaching regional teaching hospital
  Southampton University Hospital Trust (SUHT)
• Commercial and New Technologies
• Close transport links to Europe and London
• Unitary Authority (Southampton Partnership)

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Southampton a Vibrant City
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.with Challenges
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Southampton Morbidity

• Respiratory disease
• Cardiovascular disease
• Diabetes
• Infection (Hep C and HIV, TB and hospital
  acquired infection )
• Cirrhosis
• Dental disease
• Mental health
• Demographic pressures elderly care
• Long term conditions consume 80 of health budget

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Southampton Public Health

• Life expectancy 3 years lower in poorest areas
• Mental health morbidity (incapacity benefit)
• Social morbidity (homelessness, drugs, alcohol,
  unemployment and domestic violence)
• Obesity
• Poor dental health in children
• High use of secondary (hospital care)
• Pressure of new communities and population
  mobility
• Lower educational attainment
• Teenage pregnancy

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Everyday in Southampton

• 7 babies are born
• 5 people die
• 2 teenagers get pregnant
• 58,000 people smoke 800,000 cigarettes
• 10,000 people drink harmful amounts of alcohol
• 7,000 people see their GP or practice nurse
• 1 person falls and breaks their hip
• 130 people attend AE
• 200 people attend a Walk in Centre
• 142 people are in a hospital bed
• 475 people attend out patients

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Southampton PCT annual allocation 361 million
(1,438 per head)

• Acute hospitals 161 million (45)
• Community services 49 million (13.5)
• Ambulance 5.5 million (1.5.)
• Primary care 31million (8.5)
• Dental 10 million (3)
• Prescribing 34 million (9.5)
• Mental health 36 million (10)
• Special placements 11 million (3)
• Capital charges 7 million (2)
• Others 8 million (2)
• Corporate spend 9 million (2.5)

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PCT Five Year Strategic Plan

• Serve the City by improving health, well being
  and prosperity with an extra year of life by 2013
• Reduce health inequalities
• Gain 80 public approval including hard to reach
  communities
• Improve patient experience and outcomes
• Work within budgets
• Key public health population outcomes
• Stimulate improvement by competition,
  contestability and patient choice

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Primary care Bedrock of Modern Health System

• Affordability of health system
• Ease of access
• Patient focussed
• Public health
• Population well-being
• Community stability
• Social as well as medical model

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Traditional Primary Care

• Small independent businesses owned by the GPs
• Business model 60 years old
• Registered List
• Medical model of care
• Abdicated 24 hour responsibility 2004
• High set of patient centred professional values
  and continuity of care
• History of enterprise and innovation

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Tensions

Professional aspirations
Patient health needs and wants
Population health needs (public health)
Primary Care Contract
Government requirements
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What is primary care?

• GPs, Pharmacists, Dentists and Opticians
• Walk in Centre
• Ambulance Service
• AE
• Mental Health Community Workers
• Social Services
• Community General and Specialist Nursing
• School nursing
• Midwives

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What is Primary Care?
Pharmacist, dentists and opticians
Midwives
School nursing
AE
Community nursing
GP practice
Social services
Practice nursing
Ambulance
Specialist nurses
Walk in Centres
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Primary medical services in Southampton

• 38 practices (1 8 doctors) 140 GPs
• 36 independent practices
• 3 nurse led Walk in Centres (compliment or
  compete)
• Registered list (98 population)
• Rented, owned or leased accommodation
• New government led procurement for new model
  (APMS) - Primary care centres

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Practice Based Commissioning (PBC)

• Indicative budget for hospital, community
  services and prescribing held at practice level
  for registered list
• Contracts and procurement managed by PCT
• National tariff for hospital care (PbR)
• Changing relationship with acute hospitals (SUHT)
  
• 80 spent on patients with Long Term Conditions
• PBC commissioners or providers?

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Primary Care Contract - 2004

• National contract (GMS) based on list size
• Local contract (PMS)
• Quality outcome payment (20 income) mainly to
  support quality long term condition management
  (nationally determined)
• National or local enhanced services
• Rent and pension subsidy
• Incremental use of quality and enhanced services
  payment to support practice profits

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Enhanced services - examples

• Minor surgery
• Anticoagulation control
• Complex case management
• Primary and secondary prevention of coronary
  heart disease
• Medication management

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Commissioning primary care to improve health

• Outcome over care pathway especially long term
  conditions
• Patient experience including access
• Patient health including primary/secondary
  prevention of ill health
• Appropriate use of hospital and prescribing
  resources
• Public health
• Community well-being

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Contract performance management Balanced score
card

• Based on outcome not processes
• Composite picture with agreed domains (access,
  experience, outcomes etc.)
• Each domain populated by multiple components
• Systematic comparisons for primary care delivery
• Must take into account practice morbidity mix

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Collecting the data

• Based on self assurance with periodic checks
• Patient experience professional surveys
• Practice IT systems
• Prescribing and secondary care data
• Diagnostic data
• Screening programs
• Public health data
• Local authority data
• Most of these systems already in place

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Patient access
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Example
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Practice a b c d e f g h
I j k l m n o p q
r s t
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Critical success factor

• Primary care commissioning should be based on
  value and outcomes
• Value has to address individual patient,
  population and public health needs
• Funding structure must create the right
  incentives
• Must allow opportunities for local innovation and
  enterprise
• Information systems
• System must be transparent and outcomes publicly
  available
• Quality indicators must be owned by the
  professionals themselves

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Public Health

• Life expectancy 3 years lower in poorest areas
• Mental health morbidity (incapacity benefit)
• Social morbidity (homelessness, drugs, alcohol,
  unemployment and domestic violence)
• Obesity
• Poor dental health in children
• High use of secondary (hospital care)
• Pressure of new communities and population
  mobility
• Lower educational attainment
• Teenage pregnancy

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Health Improvement
Regional average
England average
Significantly worse than England average
Not significantly different from England average
England worst
England Best
75th Percentile
25th Percentile
Significantly better than England average
GCSE achievement (5 A - C)
Violent crime
Smoking in pregnancy
Breast feeding initiation
Obese children
Childrens tooth decay (at age 5)
Teenage pregnancy (under 18)
Adults who smoke
Under 15s not in good health
Incapacity benefits fro mental illness
Hospital stays due to alcohol
Hip fracture in over 65s
Life expectancy - male
Life expectancy - female
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Conclusion

• Successful primary care commissioning can
  stimulate pivotal role of primary care in health
  improvement
• Commissioners in partnership with the profession
  need to shape the system not micromanage primary
  care
• Core values of primary care can be retained
  within new competitive framework
• Commissioning framework including PBC will lead
  to new organisational models