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Lessons from England: NHS policy in developing primary care as the organisational focus for assessin

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Title: Lessons from England: NHS policy in developing primary care as the organisational focus for assessin


1
Lessons from England NHS policy in developing
primary care as the organisational focus for
assessing health need
  • Dr Nick Goodwin
  • Senior Lecturer
  • Health Services Research Unit, London School of
    Hygiene and Tropical Medicine

Keynote paper to The Future of Primary Care in
Europe 11-13 October, 2006 Utrecht, Netherlands
2
The Growth of Primary Care in UK
  • General practice workforce (2001)
  • GPs 30,685 (1, 1991)
  • List Size (average) 1841 (-5.4)
  • Practice staff 64,998 wte (33.4)
  • Practice nurses 11,163 (27.2)
  • Clerical staff 51,390 (35.1)

3
The Growth of Primary Care in UK
  • Workload
  • Year Consultations Per GP
  • 1975 145 million 7551 (20.7/day)
  • 1985 230 million
  • 1995 295 million 8896 (24.4/day)
  • 2005 310 million
  • 80 of people see a GP at least once a year, with
    an average of 5 visits per person

4
Reasons
  • Development of the family practitioner,
    registered list and gate-keeping role
  • Demand for community-based care to support
    long-term conditions and chronic disease
  • Increasing availability of medical cures and
    technologies
  • Search for cost-containment strategies
  • Shift in location of care from hospital to
    primary care sector
  • Political emphasis on primary care-led NHS since
    early 1980s

5
The 1980s from autonomous primary care to a new
GP contract
  • Little substantive organisational change over the
    period 1948-1987 focus is the GP practice
  • Some changes to GP contracts and conditions
  • Move towards health centres and group practices
  • Expansion in community nursing

6
The early to mid-1990s emergence of the primary
care organization
  • 1990 GP contract
  • Focus on health promotion and use of payments
    related to health targets (e.g. chronic disease
    management, screening, immunisations and
    vaccinations)
  • First indication of management in 10 care
  • 1991 Internal market reforms of the NHS splits
    purchaser (health authority) and provider (NHS
    trust)
  • Health authority purchasing (population-centred)
  • GP fundholding (patient-centred)

7
Why Fundholding?
  • Reduce costs
  • Financial incentives to GPs to manage prescribing
    budgets and be more judicious in referral
    practices
  • Contractual leverage over hospitals
  • Extend local facilities
  • Encourage new services provided locally
  • Provide choice
  • Offer patients alternative providers of care and
    improve access

8
Innovations in Primary Care Organisations
Increasing ability to hold own budget and enjoy
purchasing autonomy from health authority
9
Innovations in Primary Care Organisations
Health Authority-Led Models
Locality purchasers/ commissioners
GP consultation schemes
Conventional
Clinical commissioning directors
Increasing ability to hold own budget and enjoy
purchasing autonomy from health authority
10
Innovations in Primary Care Organisations
Health Authority-Led Models
Fundholding Models
Community FHs
Standard FHs
Locality purchasers/ commissioners
GP consultation schemes
FH Consortia
Conventional
Multifunds
Clinical commissioning directors
Increasing ability to hold own budget and enjoy
purchasing autonomy from health authority
11
Innovations in Primary Care Organisations
Adapted from Mays N Dixon J (1996) Purchaser
Plurality in UK Health Care, Kings Fund
Publishing, London
Health Authority-Led Models
Fundholding Models
Hybrid Models
Community FHs
Standard FHs
Locality purchasers/ commissioners
GP consultation schemes
FH Consortia
Conventional
Extended FHs
Multifunds
Total Purchasing Pilots
Clinical commissioning directors
Increasing ability to hold own budget and enjoy
purchasing autonomy from health authority
12
What did these innovations achieve?
  • Fundholding
  • Reduced rise in prescribing costs
  • Development of more practice-based services
  • Providers more responsive to demands
  • but
  • Little change in referral rates
  • Little change in level of patient choice
  • Institutionalized two-tier access to care
  • High transaction costs for both purchasers and
    providers

13
What did these innovations achieve?
  • Total Purchasing (Hybrid)
  • Some TPPs were able to substitute hospital
    services with local alternatives and so reduce
    referrals and lengths of stay significantly
  • but
  • Progress slower in larger groups as TPPs created
    their own organisational bureaucracies
  • Variable impact mostly small-scale and
    incremental changes
  • Increased to cost of running the local health
    system

14
What did these innovations achieve?
  • GP and Locality Commissioning (HA-support)
  • Some improvements in local services, but less
    speedy or widespread than in fundholding
  • Greater commitment to addressing public health
    needs and tackling inequalities
  • Development of clinical governance and
    peer-accountability
  • Transaction costs lower, but growth in uncosted
    factors such as time in meetings and negotiations

15
1997-2002 Towards a Single Model the Primary
Group and Trust
  • New Labour Government
  • Devolution
  • the UK splits into 4 health systems
  • The New NHS in England
  • Abolished fundholding and its variants, but
    retained the internal market
  • Emphasised importance of PCOs in leading change
    and managing quality in primary care
  • Wanted more organised approach, so makes
    membership of a PCO compulsory

16
Primary Care Groups and Trusts, 1997-2002
Health Authority-Led Models
Fundholding Models
Hybrid Models
Community FHs
Standard FHs
Locality purchasers/ commissioners
GP consultation schemes
FH Consortia
Conventional
Extended FHs
Multifunds
Total Purchasing Pilots
Clinical commissioning directors
Increasing ability to hold own budget and enjoy
purchasing autonomy from health authority
17
Primary Care Groups and Trusts, 1997-2002
Primary Care Groups
Primary Care Trusts
Level 2 Devolved responsibility for
commissioning, but remain sub-committee of the
health authority
Level 1 GPs and nurses advise health authority
Increasing ability to hold own budget and enjoy
purchasing autonomy from health authority
18
Primary Care Groups and Trusts, 1997-2002
Primary Care Groups
Primary Care Trusts
Level 4 As per level 3, but with added
responsibility for managing community care (e.g.
district nursing)
Level 2
Level 1
Level 3 Free-standing Trust, commissioning
services for local populations, accountable to
the health authority
Increasing ability to hold own budget and enjoy
purchasing autonomy from health authority
19
The Velvet Revolution
  • A system that is led by local professionals

20
The PCT organisation is led by local
professionals
  • PCT Board
  • Chair, 5 PEC members, 5 Non-execs
  • Professional Executive Committee
  • Chief Executive,
  • Chair (normally a GP),
  • Directors of Finance, Public Health, Primary care
  • 2 Social Services members,
  • 1 Public Health member,
  • Lay Representative
  • Medical Practitioners (no more than 7),
  • Nurses (no more than 7),
  • Other Professionals (no more than 7)

21
Shifting the Balance of Power
  • Accelerated the process of PCT development
  • PCTs established in all areas
  • April 2006 there were 303 PCTs nationally
  • PCTs control 80 per cent of total NHS budget
  • Health authorities were phased out replaced by
    Strategic Health Authorities

22
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23
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24
The Roles of Primary Care Trusts
  • Assess the health needs of all the people in
    their local community
  • Improve the health of local communities

25
The Public Health Agenda for PCTs
  • Public health directorate
  • Public health strategies and programs for
  • Prevention of ill-health and promotion of
    well-being
  • Tackling inequalities
  • Integrate fragmented way public health issues
    being managed by fostering community-based
    multi-agency partnerships
  • Creation of joint health and social care plans

26
Progress
  • PCTs have made limited progress
  • Decision-making system dominated by health
    professionals and concerned primarily with
    treatment, care plans and disease management
  • Chronic shortage of public health expertise
  • Time pressures
  • the process of partnership building between
    agencies
  • public health not a priority compared with
    productivity measures (i.e. waiting lists)
  • Public health initiatives not core funded -
    reliant on grant bids
  • Constant organisational change
  • Public health plans not converted into
    commissioning or procurement process

27
  • Combining primary care and public health is like
    mixing oil and water
  • G. Meads et al 1999,
  • Mixing oil and water how can primary care
    organisations improve health as well as deliver
    effective health care,
  • Health Education Authority, London

28
The Roles of Primary Care Trusts
  • Assess the health needs of all the people in
    their local community
  • Improve the health of local communities
  • Manage local contracts for services from primary
    care providers ensuring quality

29
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30
The New GP Contract
  • GP income related to achieving quality standards,
    in 2004 these being
  • Coronary heart disease (121 points)
  • Hypertension (105)
  • Diabetes (99)
  • Asthma (72)
  • COPD (45)
  • Mental health (41)
  • Stroke/TIAs (31)
  • Epilepsy (16)
  • Cancer (12)
  • Hypothyroidism (8)

31
The New GP Contract
  • Coronary Heart Disease
  • 15 clinical indicators to meet, for example
  • CHD 7. The percentage of patients with CHD whose
    notes have a record of total cholesterol in the
    previous 15 months
  • Points scored 1 point (25) to 7 points (90)
  • M Roland, 2004, NEJM, 1448-1454

32
The New GP Contract
  • Coronary Heart Disease
  • CHD 8. The percentage of patients with CHD whose
    last total cholesterol (measured in last 15
    months) is 190mg/dL or less
  • Points scored 1 point (25) to 16 points (60)
  • M Roland, 2004, NEJM, 1448-1454

33
The New GP Contract
  • Patient experience indicators
  • Conducting and acting on patient surveys (3)
  • Booking consultations at longer intervals (1)
  • Organisational indicators
  • Records (19)
  • Information to patients (8)
  • Education and training (9)
  • Practice management (10)
  • Medicines management (10)

34
The New GP Contract
  • With one mighty leap, the NHS vaults over
    anything being attempted in the United States,
    the previous leader in quality improvement
    initiatives
  • Shakelle P, BMJ editorial, 2003, 326 457-8

35
The New GP Contract
  • Impact
  • Practice performance in first year massively
    exceeds predicted levels, leading to budget
    deficits in PCTs (1m-2m each c500m)
  • Early evidence suggests real change in practice
    activity towards disease management activities
  • Zero-sum competition as contract specifications
    grow less holistic, more disease focused
  • In 2006/7, new domains in the contract will
    include
  • depression, dementia, learning disability, atrial
    fibrilation, kidney disease, obesity, palliative
    care

36
The Roles of Primary Care Trusts
  • Assess the health needs of all the people in
    their local community
  • Improve the health of local communities
  • Manage local contracts for services from primary
    care providers ensuring quality
  • Encourage and ensure access to primary care
    services

37
Out of Hours
38
The Roles of Primary Care Trusts
  • Assess the health needs of all the people in
    their local community
  • Improve the health of local communities
  • Manage local contracts for services from primary
    care providers ensuring quality
  • Encourage and ensure access to primary care
    services
  • Listening to the views and demands of patient and
    local people

39
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40
The Roles of Primary Care Trusts
  • Assess the health needs of all the people in
    their local community
  • Improve the health of local communities
  • Manage local contracts for services from primary
    care providers ensuring quality
  • Encourage and ensure access to primary care
    services
  • Listening to the views and demands of patient and
    local people
  • Broker partnerships with local authorities to
    commission and provide services in a more
    integrated and appropriate way

41
Local Authority Social services Welfare Housing Le
isure
42
The Roles of Primary Care Trusts
  • Assess the health needs of all the people in
    their local community
  • Improve the health of local communities
  • Manage local contracts for services from primary
    care providers ensuring quality
  • Encourage and ensure access to primary care
    services
  • Listening to the views and demands of patient and
    local people
  • Commissioning/purchasing services from secondary
    care providers

43
Independent Sector
44
The New World of Primary Care in England
45
2004-present The New World of Primary Care
  • New Contract with GP practices
  • Quality and Outcomes Framework
  • Foundation Trusts and provider plurality
  • Patient Choice
  • Payment by Results
  • National tariffs for items of service
  • Practice-Based Commissioning
  • Growth of new independent practice associations
    with both provider and commissioner functions
  • PCT mergers
  • move to 152 PCTs in October 2006 with a closer
    strategic commissioning role linked to local
    authorities

46
Local Authority Social services Welfare Housing Le
isure
47
Payment by Results and Practice-based
Commissioning
  • Payment by Results will place further stress on
    PCT budgets
  • Practice-based commissioning is the key mechanism
    that PCTs can use to combat PBR and invest in CDM

48
Lessons from England
  • PCOs can be effective as the organisational focus
    for addressing health needs
  • Integrate primary and community care
  • Improve quality of care provision and prescribing
    through clinical governance procedures and
    quality-based contracts
  • Re-invest in chronic disease models of care by
    investing in local, cost-effective services
  • Working with local authorities to develop new
    partnerships, teams and services

49
Lessons from England
  • However, there are many problems
  • Reconciling the promotion of choice and
    contestability with integrated care management
    and social inclusion
  • Emphasis on productivity rather than equity,
    efficiency or public health
  • Giving primary care professionals the incentives
    to participate in the process
  • Enabling creative destruction in provider
    market whilst being responsible for peoples
    continuity of access to services

50
The Future NHS
  • NHS becomes an insurance organisation, funded
    through taxes
  • Alignment of health and social care policies,
    funding and accountabilities
  • PCTs (or derivatives) become procurement agents
    tasked with market management to ensure
    enrolled patients get comprehensive services
  • Growth of independent providers/public firms in
    primary and secondary care, especially of managed
    care agencies (IPAs) offering integrated care
    packages
  • Growth of new workforce patterns and new training
    and education systems for professionals
  • Self care, individualised care, choice and direct
    payments, e-consultations, e-prescriptions
  • End of the traditional hospital institution, rise
    of networked care
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