Transcript Overview of Primary Care in the UK

Primary Care in the UK
What Can We Learn?
Cypress Health Region
September 2004
Overview of the NHS
The National Primary Care Development
Team
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Launched in February 2000 by 4
people
Purpose was to establish the
National Primary Care
Collaborative
NPDT Philosophy
“To have a small lean central team,
maximizing the participation,
ownership and resources in the
field…this is the best way to create
sustainability in improvement.”
National Primary Care Collaborative
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Bring about rapid improvement in patient care
through utilization of tools and techniques of
quality improvement (PDSA cycles)
help practices and PCTs systematically improve
their services to better meet the needs of their
patients.
Develop a cohort of people with the knowledge
and skills to apply quality improvement methods
to local priorities
Initial Focus of the Collaborative
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3 areas of focus to begin with which are important
to patients and were key priorities for practices
and PCTs
Improving access to primary care
Improving care for patients with proven
coronary heart disease
Improving access to routine secondary care
services by developing the primary and
secondary care interface
After Only Two Years…
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Average waiting time to see a GP reduced
by 60%
Fourfold reduction in mortality for
patients with coronary heart disease
Multiple pathways redesigned between 1o
and 2o care, reducing waiting times and
improving patient experiences
By March 2003, the Collaborative
involved over 2000 practices
serving almost 11 million patients,
making it the largest health
improvement program in the
world.
Healthcare Funding
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Healthcare funding from Federal
government
PCTs are focus of funding –
receive ~75% of healthcare
funding
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Each PCT receives an annual allotment of money
from the Department of Health determined by the
number of patients and the characteristics of these
patients
Must be accountable for remaining within their
allotted budget, and in achieving the clinical targets
set out by the NHS.
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As long as the PCT is managing their patients and
money appropriately, they have the freedom to use
their budget as they see fit. Should a PCT overspend
their budget, the Strategic Health Authority will
assume tight control of the PCT's spending to bring
them back onto track quickly.
Primary Care Trusts (PCT)
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Equivalent to SK Health Regions
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Local health organizations responsible for managing local health
services
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Ensure all other health services are provided, including hospitals,
dentists, opticians, mental health services, NHS Walk-In Centres,
patient transport (including accident and emergency), population
screening, pharmacies and opticians.
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Work with local authorities and other agencies that provide health
and social care to ensure community’s needs are being met
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Because they are local organizations, they are in the best position
to understand and meet needs of the community
How the Money is Spent…
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The PCT uses their budget to
purchase health services, employ
various clinicians who work with
patients, and employ PCT staff.
Health services are funded in a
variety of ways:
Secondary Care Funding
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Hospital and Specialist Services:
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purchased on a contract basis
the number of needed services (ex:
700 hip replacements) are estimated at
the start of each budget year.
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If additional services were required by
year-end, the difference is paid to the
provider by the PCT
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Each PCT determines requirements for
the service provider to ensure that high
quality care is being provided (patient
waiting times to access the services,
quality of services, etc)
If a particular provider is not meeting
these requirements, the PCT will
contract with another provider,
including those in the private sector.
Primary Care Funding
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GP services
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Contract basis
GP practices are allotted a yearly budget based on the number of
registered patients they serve and the ethnicity and deprivation of
these patients
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Each practice decides how to use this money to best serve their
patients, and meet the NHS and PCT targets for healthcare
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Many practices employ nurses and other healthcare professionals to
provide a variety of services for their patients.
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Budgets must also include drug costs for all medications prescribed by
the GPs
Example Practice Budgets
Practice
Budget
(£)
Year
End
+/-
%
+/-
List
Size
Drs A
697617
770879
73262
11
4497
Drs B
1478625
1549727
71102
5
11626
Drs C
481770
462737
-19033
-4
3316
Drs D
1263695
1214213
-49482
-4
9206
Incentive Schemes
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A way of promoting quality patient
care, not quantity of care
Incentive targets are predetermined
by the NHS and individual PCTs
Incorporate a variety of focus areas
(prescribing, disease management,
access, resource utilization, etc)
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When a practice meets an incentive target
at the budget year-end, predetermined
financial “bonuses” are awarded to the
practice
Practice is free to use the money how
they see fit…usually recycled back into
the practice to better improve patient
care
Significant potential monetary gains
Examples of Incentive Targets
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80% of target population receive flu
vaccination
100% of patients able to see their
GP within 48 hours of requesting an
appointment
Practice remaining within their
allotted budget
Primary Care Funding
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Nursing Services
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home care and public health nurses
employed by the PCTs.
Practice nurses (Nurse Practioners),
located in GP practice are employed by
each individual practice
Primary Care Funding
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Pharmacy Services
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How services will be commissioned is changing with
the introduction of the new Pharmacy Contract.
Looking at an alternative way to reimburse how
pharmacies are paid. Currently, pharmacies are paid
the "set" cost of the drugs and a small dispensing fee,
with the majority of profit coming from savings made
on drug purchase price negotiations, and front store
items.
The idea is to be paid in a similar way to the GPs based on quality of the service, not the quantity - with
the elimination of the dispensing fee. Pharmacies will
receive a fee based mainly on the number and
characteristics of the patient population they serve.
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Pharmacy Services
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The PCT employs clinical pharmacists who
spend time in the GP practices performing
medication reviews, patient education, and
assisting GPs in meeting their prescribing
targets.
The PCT is also looking to employ “pharmacy
registrars” who will work in community
pharmacies helping the existing pharmacist
develop a more clinical practice, as well as
freeing them up to spend time in GP
practices
What Do They Do So Well?...
(North Bradford PCT)
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Positive attitudes toward healthcare
by all involved
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Excited about what has been
accomplished and what can yet be
done
Pride in their work
Willingness to embrace change
What They Do So Well…
(North Bradford PCT)
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Information and experience sharing
throughout the NHS and PCTs
Not satisfied with the status quo
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Constantly looking for innovative ways
to improve healthcare
Majority of top executives are still
front-line workers
Successful Philosophies…
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Successful changes do not occur all at once. Small
continual changes have a bigger influence over
the whole picture.
To implement timely change, it is important to
work with the "early adopters" rather than wait
for everyone to come on board.
Committees are an inefficient way to make
decisions regarding change – consensus is never
reached in a timely fashion
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individuals are empowered to make decisions,
rather than relying on committee decisions
Ideas are "bounced off" several team members in a
parallel position before they are initiated
Successful Philosophies…
JFDI…
Key Concepts We Can Learn From…
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Support for all levels of healthcare
from management/government
Accountability on all levels
Adaptability to change
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Work with early adopters
Power given to frontline workers
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Many top execs are still frontline HCPs
Advanced Access
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Restructuring of services provided
and work flow in physician practices
have resulted in:
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Patients can see a primary healthcare
provider within 24hrs of requesting an
appointment (48hr to see their GP)
Increased workplace satisfaction for all
involved healthcare professionals
Advanced Access
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Requires no additional funding
Efficient provision of healthcare
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Patients receive care from the most
appropriate health care professional
Relatively simple to incorporate
Patients & Physicians/HCPs benefit
HQC initiative
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Providing support for interested
practices
Alternative Physician Reimbursement
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Adaptable option for physician
payment especially in rural areas
Increase physician accountability
(patient outcomes, resource
utilization)
Promotion of team approach to
patient care
Improved patient outcomes
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Greater potential earnings for physicians
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Physicians have more control over their
practice
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entice new practioners
In the best position to determine which
services are needed to serve their patients
Work with early adopters
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Successful SK practices are best evidence for
future adopters
Focus on Primary Care…
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Uk system has realized that it is
more efficient to spend money on 1o
care rather than 2o care
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Focus on health promotion, disease
prevention and management
When you focus on 1o care, you
eliminate much of the demand on 2o
care – with the resultant cost savings
being used to fund further 1o care
development
Empower Healthcare Professionals
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Allow front-line workers the ability to
develop and implement change
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Have a better understanding of what is needed
and what is possible
Eliminate much of the “red tape” process
that often hinders positive and necessary
change
Provide support (financial, time, human,
educational, etc…)
Private Healthcare Providers
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Many of the services received by UK
patients are provided by private
organizations
Competition between providers causes
improved services and lower costs
Still a public system as patients do not
pay out-of-pocket for these services
Challenges For Us…
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Healthcare provider attitudes
Patient attitudes
Unions
Funding (provincial vs federal)
Lack of resources (human, financial)
History of extensive committee
decision making
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Slow implementation of change and
development
Challenges…
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Resistance to change
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Fear of failure
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Tendency to try to implement major
change rather than focusing on small
continual changes
Lack of IT systems
The 5 Simple Rules
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5.
See things through the patients’
eyes
Find a better way of doing things
Look at the whole picture
Give frontline staff the time and
tools to tackle the problems
Take small steps as well as big
leaps
The 3 R’s
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Renewal: More modern buildings and
facilities, new equipment and IT, more
and better trained staff
Redesign: Services delivered in radically
different ways with a much greater use of
clinical networks to better co-ordinate
services around the patient
Respect: Mutual respect between
politicians, managers, healthcare
organizations, frontline providers and the
patients they serve
Final Thought…
“If you don’t take change by the
hand, it will grab you by the throat”
-Winston Churchill