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

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Lessons from EnglandNHS 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
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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)

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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

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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

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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

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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)

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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

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Innovations in Primary Care Organisations
Increasing ability to hold own budget and enjoy
purchasing autonomy from health authority
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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
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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
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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
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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

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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

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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

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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

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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
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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
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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
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The Velvet Revolution

• A system that is led by local professionals

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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)

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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

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The Roles of Primary Care Trusts

• Assess the health needs of all the people in
  their local community
• Improve the health of local communities

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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

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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

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• 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

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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

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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)

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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

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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

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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)

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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

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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

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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

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Out of Hours
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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

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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

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Local Authority Social services Welfare Housing Le
isure
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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

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Independent Sector
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The New World of Primary Care in England
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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

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Local Authority Social services Welfare Housing Le
isure
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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

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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

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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

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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