Transcript GP_Contract 121KB PPT - Migraine in Primary Care Advisors

MIGRAINE IN PRIMARY CARE ADVISORS
Implications of the new GP contract to
headache management
Overview
• Review of the new GP contract
• Identifying opportunities in the new
contract
• Designing audits based on targets in
the contract
Review of the new GP contract
Overview
• More flexible service provision
• Support of human resources and
infrastructure modernisation
• Investing in primary care services
• Rewarding clinical and organisational
quality
• Providing better services for patients
• Implementation
More flexible service provision
• Address issues of practice workload
• Service categorisation
– Essential services: compulsory
– Additional services: usually provided
– Enhanced services: specialist and optional
• PCOs ensure patient access to services not
compromised
• GPs have balance between work and
personal commitments
• PCOs take full responsibility for out-of-hours
services
• PCOs can provide or commission services
Support of human resources and
infrastructure modernisation
• Improve working lives of GPs
– 3-module approach: skills, knowledge and experience
– Reward experience
– Support work / life balance
• Enhance practice management
• Additional support for rural and remote practices
• Practice infrastructure modernised
– New / modernised premises
– Investment in information management and technology
(IM&T)
• Flexible service provision by supported individuals
Human resource development
• New career structure
– Skills development, primarily for newly qualified
GPs (skills rather than titles)
– Special interest development – e.g. GPwSI
services
– Clinical leadership – e.g. education, mentoring,
governance, appraisal
• Learning and personal development
supported through protected time
– Practices to develop support systems
• Proper funding of appraisals in PCOs
Supporting practice staff: nurses
• Quality framework applies to practice
team, rather than the GP in isolation
• Nurses supported to take on advanced
and specialised roles
– Clinical supervision and appraisal
– Access to professional development and
IM&T
– Roles in first contact care, chronic disease
management and preventive services
Supporting other practice staff
• Support practices to develop greater
skill mix
– Registered nurses
– Pharmacists
– Allied health professionals
• Professionals work at all levels as part
of the practice team
– Involved in practice decision making that
impacts on their work
Investing in primary care services
• Guaranteed level of resources allocated
through PCOs
• Average practice income will rise
• Practices have flexibility in how they spend
money received
• Money will flow according to patient need
• Investment in advanced services
• Separate allocations to premises
• Definition of pensionable pay broadened
– Real benefit
Service categorisation
Essential services (compulsory)
• Management of ill patients back to
health, reflecting patient choice
• General management of the
terminally ill
• Management of chronic disease in
discussion with the patient
Service categorisation
Additional services (opt out possible)
• Cervical screening
• Contraception
• Vaccinations and immunisations
• Child health surveillance
• Maternity services
• Minor surgery
Service categorisation
Enhanced services (specialist and
optional)
• Essential/advanced services delivered
to a higher standard
– e.g. extended minor surgery
• More specialist services
– GPwSIs
– Primary-secondary care interface
– Specific local needs
– Piloting innovative services
Out-of-hours service
Possible options
• NHS Direct / 24
• GP co-ops
• NHS walk-in centres
• Practice partnerships
• Paramedics
• Pharmacists
• A&E departments with GPs and primary care
nurses
• Commercial deputising services
• Social work services
Rewarding clinical and
organisational quality
• Major focus on quality and outcomes
• Rewards practices for the quality of
care delivered to patients
• The framework
– Clinical domain
– Organisational domain
– Patient experience domain
– Additional services domain
• Implemented by annual review,
including a practice report and a visit
by the PCO
Clinical domain
Essential services but provided at
enhanced level
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CHD, including LVD
Stroke and TIA
Hypertension
Hypothyroidism
Diabetes
Mental health
COPD
Asthma
Epilepsy
Cancer
No headache!
Indicators for each domain
• Based on best available evidence
– But evidence may change and has to be
updated
• Number kept to a minimum
• Data should be useful for patient care
– Not for audit only
• Obtainable from existing practice
systems
Clinical indicators
1. Structure: Medical records
2. Process: Diagnosis / initial
management
3. Outcome: Ongoing management
Organisational domain
• Records and information
• Communicating with patients
– Only two questionnaires currently
approved
• Education and training
• Medicines management
• Clinical and practice management
Patient experience domain
• Patient survey
• Consultation length
• Major opportunity for headache?
Additional services domain
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Cervical screening
Child health surveillance
Maternity services
Contraceptive services
Providing better services
for patients
• Services designed around patients’ needs
• Patient Services Guarantee ensure patients
continue to receive primary care services
• Patients register with practice rather than GP
– But retain the choice to see an individual GP
• Empowering patients to manage their own
conditions
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Improving public education
Developing the skill mix across primary care
Developing ‘expert patient’ schemes
Working with community pharmacies
Benefits to patients
• Increased resources available
• Allocation of resources according to patient
need
• Choice of practice and practitioner
• Patient Services Guarantee
• Aim for higher quality services
• Feedback via practice surveys and
involvement in service development
• Initiatives for patients to manage demand for
services
• Consultations at 10-minute intervals
Patient Services Guarantee
• Access to wide range of services in primary
care
• Most practices deliver the full range of
additional services
• Extending patient choice
– Choice of service provider
– Choice of additional service provider (when
practice opts out)
– Availability of parallel additional services
– Choice of advanced service provider
Working in partnership
• Development of management and education
programmes for self-care
• Development and support of Expert Patient
initiatives
• Supporting non-GP chronic disease
management schemes
• Promotion of Doctor Patient Partnership and
health charity initiatives
• Promoting education of young people via the
National Curriculum`
– Possible major opportunity
Implementation
• NHS contract between the local PCO
and the practice
– Services provided
– Level of quality
– Infrastructure and support
– Financial resources
• Teamwork encouraged with GPs and
other professionals
Alternative providers
• PCOs can commission or provide
services
– Maximum flexibility to commission
enhanced services, including from the
private sector
– Essential primary care may also be
provided by GP walk-in centres
– From 2006, what are now specialist
services can be provided in primary care
Contract review
• Formal review process
– Annual return from the practice
– Annual review, typically involving a visit
• Evidence-based review in the medium
to long term
First steps
• Doctors’ and Dentists’ Review Body
asked to endorse the agreement
• Primary legislation introduced
• Contract implemented in a phased way
• Substantial implementation will occur
in 2003/04
• Problem with underfunding
Identifying opportunities
in the new contract
Concepts
• In the future the career of medicine will
involve collecting competencies
– Core
– Specific
• Developing relative competencies in
headache management
– Specialist GP (GPSI)
– General GP
– Nurses
– Pharmacists
Service
delivery
Initiatives relevant for
headache management - 1
• Management of chronic disease in
discussion with the patient (essential
service)
– Communicating with patients a key organisational
domain
– Improving public education
– Patient input via practice surveys and
involvement in service development
– Bringing general GPs, nurses and others up to
standards
• MIPCA guidelines for migraine and CDH
emphasise patient-doctor partnership
Initiatives relevant for
headache management - 2
• Enhanced services encourage
development of more specialist
services
– GPSI schemes
– Primary-secondary care interface
– Clinical leadership schemes
• MIPCA guidelines for GPSI in headache
and setting up headache clinics in
primary care
Initiatives relevant for
headache management - 3
• Education and training a key
organisational domain
– Learning and personal development
supported through protected time
– Education and mentoring a key part of
clinical leadership
– Improving public education and promoting
education of young people in schools
• Opportunity for development of MIPCA
diploma for headache education
Initiatives relevant for
headache management - 4
• Development and support of ‘expert
patient’ schemes
– Promotion of health charity initiatives
• MAA is funded to provide a specialist
patient programme for headache
Initiatives relevant for
headache management - 5
• Supporting practice staff
– Quality framework applies to practice team rather than to
GP
– Nurses supported to take on advanced and specialised
roles
• First contact care, chronic disease management and
preventive services
– Pharmacist and allied professionals included in practice
team
– Teamwork encouraged between GPs and other
professionals
• MIPCA guidelines for nurses and pharmacists, and
encouragement of the primary care headache team
• Lobby for NICE headache guidelines via Headache
UK and/or SIGN
Primary care
Community nurse
Optician
Pharmacist
Practice
nurse
Specialist
care
Ancillary
staff
Primary care
physician
Physician with expertise
in headache:
GP; PCT; specialist
Dentist
Complementary
practitioner
Patient
Associate team
Core team
Copyright MIPCA
2002, all rights
reserved
Initiatives relevant for
headache interventions
• Headache is not one of the clinical domains
• Lobby to include headache
• MIPCA guidelines comply with clinical and
organisational indicators
– Based on best available evidence
– Assessment based on diagnosis and initial and
ongoing management
– Patient communication important
– Obtain NICE endorsement to raise status of
headache
Production of educational packages
• Education and training of professionals and
the public to be supported
• MIPCA plans to develop a modular education
programme for headache
– GPSIs
– GPs
– Nurses and other professionals
• Courses for educators of professionals and
the public (training the trainer)?
– Specialist patients
Outputs for governance
• Audits
– Clinical indicators
– Patient surveys
– Evaluating professional development
• Education and training
• Link with RCP to demonstrate that specialist
standards are being met
– Appraisal
Design of audits
Quality indicators for
clinical domains
• Based on best available evidence
• Data needs to be useful for patient
care, and not just for audits
• Indicators
– Medical records
– Diagnosis
– Initial management
– Ongoing management
• Patient surveys
Epilepsy
• Records:
– Register of patients receiving drug treatment
• Ongoing management:
– Seizure frequency over past 15 months for
patients (≥ 16 y) on drug treatment
– Record of medication review over past 15 months
for patients (≥ 16 y) on drug treatment
– Proportion of patients (≥ 16 y) on drug treatment
convulsion free for last 12 months
Asthma
• Records:
– Register of patients receiving drug treatment for
asthma over previous 12 months
• Initial management:
– Proportion of patients (≥ 8 y) with diagnosis
confirmed by specific testing
• Ongoing management:
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Smoking status (14-19 y and ≥ 20 y)
Smoking cessation advice given
Asthma advice given over past 15 months
Record of influenza immunisation in preceding
Autumn / Winter
Possible audits for headache
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Clinical indicators
Education and training
Effects on practice
Management of audits
Clinical indicators
Records
• Register of patients with headache
• Register of patients receiving drug
treatment for headache
Clinical indicators
Diagnosis / initial management
• Proportion of patients diagnosed with different
headache subtypes (migraine, TTH, CDH, cluster,
sinister) over the past 12 months
• Record of medication history
• Record of co-morbidities
• Patients self-referred / referred by another
professional (e.g. pharmacist)
• Patients given management education / advice
• Patients sent for procedures / referral
• Patients given a headache diary or other
questionnaires to complete
• Patients treated with prescribed drugs: acute and
prophylactic
Clinical indicators
Ongoing management
• Register of follow-up appointments
• Record of headache status
• Medication compliance review
• Completion of headache diaries and other
questionnaires
• Record of patients whose treatment (acute
and prophylactic) was changed
• Success of initial and follow-up medications
Education and training
• Record of personal learning plans
• Annual appraisals of primary care team
(GPs, nurses, others)
• Review of patient surveys
Effects on practice
• Record of practice team arrangements
• Record of time and resources spent
dealing with headache
• Number of patients diagnosed
• Number of patients on acute and
preventive treatments
Audit toolbox
• Record forms
– Headache history questionnaires
– Patient checklists
– Headache diaries
– Impact and other questionnaires
• Audits conducted by nurses and other
practice staff