David ColinThom

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David Colin-Thomé

• National Clinical Director for Primary Care,
  Medical Adviser Commissioning and System
  Management Directorate and clinical lead for 18w
  programme
• Former GP, Castlefields, Runcorn 1971-2007
• Honorary Visiting Professor,Centre for Public
  Policy and Management, Manchester University
• Honorary Visiting Professor, School of Health,
  University of Durham

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Health Gain

• it is estimated that about five years of the
  30-year increase in life expectancy in the 20th
  century can be attributed to the provision of
  health care (Bunker et al., 1994). The most
  significant reason for this gain is the diagnosis
  and treatment of coronary heart disease which
  contributes one to two years of these additional
  years of life.

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CHD

• healthcare is delivering an increasing share of
  improvements in life expectancy. For example,
  42 of the decrease in coronary heart disease
  (CHD) mortality between 1981 and 2000 is
  attributable to healthcare (1)

1 Unal B, Critchley JA, Capewell S. Explaining
the decline in coronary heart disease mortality
in England and Wales between 1981 and 2000.
Circulation 2004 109 1101-07.
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• Personal health services have a relatively
  greater impact on severity (including death) than
  on incidence. As inequities in severity of health
  problems (including disability, death, and
  co-morbidity) are even greater than are
  inequities in incidence of health problems,
  appropriate health services have a major role to
  play in reducing inequities in health.

Starfield 12/03 03-385
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Chronic Disease definition epidemiology

• This places new long term demands on health
  care systems. Not only will chronic conditions
  be the leading cause of disability throughout the
  world by 2020 if not successfully managed they
  will become the most expensive problems faced by
  our health care system. WHO, 2002 1

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The New Clinical Paradigm

• While the global disease burden has been
  shifting towards chronic conditions, health
  systems have not evolved to meet this changing
  demand. Care is fragmented, focused on acute and
  emergent symptoms, and often provided without the
  benefit of complete medical information WHO
  (2002) 1

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LTC

• 50 of people with LTCs have not been told about
  treatment options
• 25 do not have care plan
• 50 do not have a self care plan
• 50 medicines are not taken as intended.

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Public Service Agreement
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LTC updates

• Hospital Episodes Statistics (HES) 2005/06 data
  on emergency bed days on December 06 is showing
  a 5.4reduction in emergency bed days in PSA
  2003/04 target baseline (some 1.7million bed
  days) despite a 5 increase in emergency
  admissions in 05-06
• Official launch of the Combined Predictive Model,
  the final tool delivered by the Kings Fund.
  This tool combines both hospital and GP data to
  not only increase positive power of prediction
  but predict people who have never had a hospital
  admission.

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Choice

• Choice embraces three key components designed to
  improve peoples overall experience by providing
  them with more
• Power to shape their pathway through services and
  keep control over their lives
• Preferences to choose how, when, where and what
  treatments they receive
• Personalised services organised around their
  lifestyles

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Primary Care Reform

• GP contracts
• Fairness in PC
• Quality and Outcomes Framework
• Pharmacists contract
• Nurse leadership (other clinicians)
• Practitioners with Special (clinical) Interests
• Practice Based Commissioning
• Capital into primary care
• Primary care services as social capital

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Our health, our care ,our say a new direction
for community services (www.tso.co.uk/bookshop)

• Ambition
• Enabling health, independence and well being
• Better access to GP
• Better access to community services
• Support for people with longer term needs
• Care close to home
• Ensuring reforms put people in control
• Making sure change happens

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Range of White Paper LTC commitments

• Bigger emphasis on self care and integration
• Requirement for multidisciplinary teams/networks
• Universal case management for VHIUs
• Personal Health and Care Plans
• Assistive Technology
• 24/7 single point of contact for people with
  complex needs

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Care Plans

• In addition the White Paper Our Health Our Care
  Our Say makes a commitment
• By 2008 we would expect everyone with both long
  term health and social care needs to have an
  integrated care plan if they want one. By 2010
  we would expect everyone with a long term
  condition to be offered a care plan. We will
  issue good practice guidance in early 2007.

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Benefits of a first contact in primary
care.(Starfield)

• Higher patient satisfaction with health services
• Lower overall HS expenditure
• Better population health indicators
• Fewer drugs prescribed per head of population
• The higher the number of family physicians the
  lower the hospitalisation rate.

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General Practice(Roland and Wilson)
We identify three areas in which British general
practice performs well, leading both
international policy analysts and the public to
their favourable conclusions Equity
Quality Efficiency and three important
characteristics that contribute to this
success Co-ordination Continuity
Comprehensiveness
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General Practice and Health Inequalities (Roland)

• Practices in affluent and deprived areas
  achieving the target of over 80 of eligible
  women having received a cervical smear. The
  figure shows not only that overall rates are high
  and have increased since 1990, but that there has
  been progressive narrowing of the difference
  between affluent and deprived districts since
  1990 . Similar narrowing in the social gradient
  for childhood immunisation is seen in this period
  .
• Early evidence similar in QOF

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Keeping it Personal

• Build on the best of traditional General Practice
• Primary Health Care more than general practice
• but registered population and 80 of all NHS
  clinical consultations
• 90 of care solely undertaken in primary care
• Support for self care
• Long term conditions management
• Care Closer to home
• The practice can link the wider publics health
  and bio-clinical care

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Next Stages review-Darzi (1)

• Journey so far. Improvement but.
• World class NHS-
• -fair-SoS announced strategy for reducing health
  inequalities,
• -personalised now to focus on primary care and
  LTC,
• -effective-Health Innovations Council
• - safe-Patient Safety Direct to support NPSA AND
  reduce rates of Health Care Associated Iinfections

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Next Stages review-Darzi (1)

• Major hospital change is clinically led and
  locally accountable
• And also subject to independent clinical and
  managerial assessment before out to consultation

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Next Stages review-Darzi (2)

• Deliver vision across eight areas of care
• -Maternity and newborn
• -Childrens health
• -Planned care
• -Mental health
• -Staying healthy
• -Long term conditions
• -Acute care
• -End of life care

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Next Stages review-Darzi (2)

• Exploring the introduction of an NHS
  constitution-CE to lead
• Future strategy on primary and community care

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Issues

• LA is the public health organisation
• And LTC is ?bulk of adult social care
• My experience is that best outcomes and less need
  for hospital is when social care is working
  closely with NHS in particular primary care
• So given the better funding for the NHS should
  NHS not be funding more social care?
• NHS is adequately funded if we challenged
  inappropriate and ineffective care
• Whither personal budgets?
• Is not the pathway the patients/clients?
• Who are the providers?
• Networks/Multi disciplinary accountability?
• Who wants to be the principal provider?
• So leadership locally an issue