Organisation of Primary Healthcare Systems: UK Experience, European and International Perspectives

1
Organisation of Primary Healthcare Systems UK
Experience, European and International
Perspectives

• Dr. Simon de Lusignan
• Primary Care Informatics
• Chair EFMI PCI Working Group
• GP Woodbridge Hill Surgery Guildford
• Division of Community Health SciencesSt.
  George's - University of London

2
Overview

• What is primary care
• Definition of primary care
• Consultation is the commodity that primary care
  delivers
• Informatics is an enabler of quality
• Primary healthcare in UK
• Division into Commissioner Provider
• National frameworks standards (e.g. NSF, NICE,
  Health Commission)
• UK GP as provider
• Quality based-contract - Practice Based
  Commissioning
• Information system to support primary care
• Components
• 1) Unique identifier 2) Coding system(s) 3)
  Level of interoperability
• Compare
• England Integrated National programme for IT
  Connecting for Health
• European approach Improving interoperability
  between systems
• Scotland Linkage of records using CHI (Community
  Health Index) number
• Conclusions
• Explicit quality standards, measured using IT are
  a useful component of a modern primary healthcare
  system

3
Introduction

• What is primary care?
• What is primary care informatics?

4
What is primary care?

• Based on first contact
• The first-contact health service for a patient
  who is sick or injured is staffed by trained
  primary care professionals. (Fry)
• Any problem, any time
• primary care as the specialty that sees any
  patient(s), with any combination of problems, any
  time
• Comprehensive coordinating
• first-contact care, longitudinality,
  comprehensive services, and coordination
  (Starfield)

5
Clinical consultation

• The core of healthcare delivery
• Usually one-to-one
• Biospyschosocial model of disease (Engel)
• Problems from physical, psychological
  perspectives
• Therapeutic effect of the consultation (Balint)
• Patient-centred
• Exploration of patients ideas / concerns /
  expectations (Pendleton)
• Changes
• Increased management of chronic disease
• Prevention and screening
• More consultations with healthcare assistants and
  nurses

6
Patient-centred care

• Choice patient autonomy
• Top down - e.g. Choose and book referral
• Expert patient groups
• Bottom-up change in social attitude - e.g.
  Counselling
• Responsibility for own health e.g. lifestyle
• More healthcare in the community
• Patients self monitoring e.g. Anticoagulants,
  telecare
• Tier-2 services
• Intermediate care

7
Patient-centred care (2)

• Practice based commissioning
• Practices / groups of practices taking
  responsibility for services
• Incentive to provide locally based better value
  for money services
• Enabled by informatics..
• Searchable medical records allow quality to
  measured
• NPfIT will enable healthcare records to be
  patient centred not fragmented between
  institutions

8
UK Primary Healthcare
9
Primary care in UK (in England)

• State funded system
• Division into commissioners providers of care
• Commissioners decide what care is to be
  provided
• Must implement national guidance
• NSF (National Service Frameworks)
• NICE (National Institute for Clinical
  Effectiveness) guidance
• Must meet Access Targets
• 4 hours casualty
• Same day and 48 hour access to a GP
• 2 weeks suspected cancer
• 13 weeks OPD,
• 6 months to surgery
• Inspection
• Healthcare Commission
• Many health communities have large deficits.

10
Primary care (in Scotland)

• Consensus style management
• No internal market
• Health boards
• Consensus management of primary secondary care
• Community health partnerships with social care

11
GP as provider of services

• Quality based contract

12
Quality based contract

• Points for achieving quality in
• Heart disease, Hypertension, Diabetes etc.
• Financially incentivised
• Score and financial remuneration based on
  collection of routine computer data
• Limited list of recommended computer codes
• All practice scores are in the public domain

13
Practice based commissioning

• Groups of practices coming together to commission
  and provide services
• Competition a driver to collaborate
• Will need to manage budgets to achieve savings
• Clinician led groupings
• Recommended approx 50K to 100K registered
  patients
• Larger groups needed to provide Tier 2 services
• Scope to keep and reinvest savings
• Can provide services traditionally delivered in
  hospital setting
• Contestability / competition is being allowed in
  primary care
• E.g. Allied Health

14
Information systems to support primary care

• England Integration
• Europe Interoperability
• Scotland - Linkage

15
Primary care information systems

• Problem Fragmented data across health system
• Primary care clinician needs
• Overview of patients medical history
• Practice safely efficiently
• Achieve quality
• Different strategies exist to address these
  needs
• Integration
• Systems are integrated with cross-platform
  functionality
• e.g. England Choose-and-Book
• Interoperability
• Systems exchange information
• Linkage
• A common identifier allows data to be linked
• e.g. Use of CHI number in Scotland

16
Promoting system-wide working

• Unique identifier
• England NHS number
• Europe many different systems
• Scotland CHI number
• 2) Coding system(s)
• England Migration to SNOMED CT
• Europe Usually ICPC in primary care ICD in
  hospitals
• Scotland Read and migration to SNOMED
• 3) Level of interoperability
• England Integration of systems via the
  spine
• Europe widespread use of data exchange
  protocols
• Scotland linking data using CHI number

17
Integration

• Consolidated system which updates all the
  relevant parts each time data is entered
• NHS Choose and book project used as an example
• Components
• Authenticate GP smart card password
• GP Clinical system (Mine is EMIS LV most used
  in UK)
• N3 (NHS Intranet) broadband links to surgeries
• National spine which checks each person for
  correct demographic details
• Choose-and-book application
• Link to its call centre
• PAS (Patient Administration System) in hospital

18
Integration NHS Choose and book
2. Spine
1. GP System
2. Spine

• Choose and Book
• Application

2. Spine
2. Spine
4. Hospital PAS
4. Hospital PAS
2. Spine
4. Hospital PAS
4. Hospital PAS
2. Spine
2. Spine
5. Patient call centre
2. Spine
6. SUS Secondary data
2. Spine
Link via NHSnet NHS Intranet
19
Integration NHS Choose and bookBlue NHS icon
indicates connected, Bottom left demographic
details not on spine
20
Integration NHS Choose and bookConnecting to
Choose and book application (lt1sec)
21
Selecting a service
22
Booking the appointment
23
Scotland Linking data CHI number - Community
Health Index

• This is a combination of
• Date of birth
• Gender indicator
• A number
• As up to 200 people are born on one day in
  Scotland
• A check digit
• Originally a unique identifier in Tayside
  later adopted across Scotland
• Examples of where it is used to link data

24
Types of health and community data linked
25
(No Transcript)
26
(No Transcript)
27
(No Transcript)
28
Practical uses DARTS diabetic study
Mortality Post Myocardial Infarction
alive
Years Post MI
Diabet Med 2002 19, 448-55
29
Discussion
30
Primary care

• Unique speciality with its own informatics
  subspecialty
• Able to meet challenges to raise quality
• Screening prevention
• Chronic disease management
• Effective in different systems
• commissioner-provider split
• consensus managed systems
• Incentives appear to lead to quality improvement
• Informatics is an important enabler of quality
• Consider
• Unique ID, Coding systems, Interoperability
• Simple low cost technologies may be as effective

31
Thanks for listening

• Simon de Lusignan
• St. Georges University of London
• Tel [phone]
• Email slusigna_at_sgul.ac.uk