David ColinThom

1
David Colin-Thomé

• National Clinical Director for Primary Care,
  Department of Health, England
• GP, Castlefields, Runcorn.
• Honorary Visiting Professor,Centre for Public
  Policy and Management, Manchester University
• Honorary Visiting Professor, School of Health,
  University of Durham
• Adviser to Manchester University Hospital.

2
International trends in health care Pressures

• Expectations
• Demography
• Technology
• Workforce
• Costs
• Internationalisation

3
International trends in health care Responses

• Markets
• From patients to consumers
• Separation of commissioning from provision
• Focus on chronic disease
• Skill mixing
• Clarity on pricing

4
Health Gain

• it is estimated that about five years of the
  30-year increase in life expectancy in the 20th
  century can be attributed to the provision of
  health care (Bunker et al., 1994). The most
  significant reason for this gain is the diagnosis
  and treatment of coronary heart disease which
  contributes one to two years of these additional
  years of life.

5
Benefits of a first contact in primary
care.(Starfield)

• Higher patient satisfaction with health services
• Lower overall HS expenditure
• Better population health indicators
• Fewer drugs prescribed per head of population
• The higher the number of family physicians the
  lower the hospitalisation rate.

6
Our health, our care ,our say a new direction
for community services (www.tso.co.uk/bookshop)

• Ambition
• Enabling health, independence and well being
• Better access to GP
• Better access to community services
• Support for people with longer term needs
• Care close to home
• Ensuring reforms put people in control
• Making sure change happens

7
Health reform framework
Transaction
Incentives and tariff Information and
benchmarking
Demand side
Supply-side
Choice and Commissioning
New providers and competition
Better Care Better patient experience Better
value for money
System Management Regulation
Targets, Institutions and Regulation
8
Choice

• Choice embraces three key components designed to
  improve peoples overall experience by providing
  them with more
• Power to shape their pathway through services and
  keep control over their lives
• Preferences to choose how, when, where and what
  treatments they receive
• Personalised services organised around their
  lifestyles

9
Commissioning

• is the process by which identify the health
  needs of the population and make prioritised
  decisions to secure care to meet those needs
  within available resources

10
Key lessons from past experience

• Commissioning often does little more than
  replicate existing service arrangements and
  service models
• 
  Degeling

11
PSA Targets

• I. Access to treatment
• II. Improving the patient experience
• III. Long Term Conditions Management
• IV. Health of the population

12
PSA Targets

• I. Access to treatment
• II. Improving the patient experience
• III. Long Term Conditions Management
• IV. Health of the population

13
Primary Care Reform

• GP contracts
• Quality and Outcomes Framework
• Pharmacists contract
• Nurse leadership (other clinicians)
• Practice Based Commissioning

14
Why PBC( Improvement Foundation)

• Improve services for patients
• Widen choice of providers
• Improve use of resources (reduce deficit!)
• Improve commissioning skills
• Reduce use of emergency care
• Improve clinical engagement
• Ensure ownership of patient use of services

15
Keeping it Personal

• Build on the best of traditional General Practice
• Primary Health Care more than general practice
• but registered population and 80 of all NHS
  clinical consultations
• 90 of care solely undertaken in primary care
• Support for self care
• Care Closer to home
• The practice can link the wider publics health
  and bio-clinical care

16
Clinical Case for Reconfiguration

• Specialist Centres significantly improve clinical
  outcomes in acute or critical care situations,
  such as heart attacks and stroke, trauma and
  emergencies, high-risk deliveries, and
  specialized paediatric care.
• Risks due to distance from the facility can be
  managed with better skilled first responders,
  such as paramedics.
• Local care (e.g., midwifery for uncomplicated
  deliveries) is more satisfying for non-critical
  care needs and does not consistently indicate
  poorer clinical outcomes than hospitals or
  specialist centres. In fact, patients seem more
  satisfied overall with the community-based
  services.

17

• Medical costs rise to equal the sum of all
  private insurance and Government subsidy
• Aaron Wildavskys
• Law of Medical Money

18
VFM

• Prescribing
• Out-patient care-follow up, new referrals
• Long term conditions management.
• Majority of hospital costs generated by the
  hospital

19
(No Transcript)
20
LTC

• 50 of people with LTCs have not been told about
  treatment options
• 25 do not have care plan
• 50 do not have a self care plan
• 50 medicines are not taken as intended.

21

• Personal health services have a relatively
  greater impact on severity (including death) than
  on incidence. As inequities in severity of health
  problems (including disability, death, and
  co-morbidity) are even greater than are
  inequities in incidence of health problems,
  appropriate health services have a major role to
  play in reducing inequities in health.

Starfield 12/03 03-385
22
Provider issues

• What is the usefulness of helping to bankrupt
  the funder?
• Collaboration can improve efficiency.
• Whether to compete or collaborate-the arbiter is
  assessing what would be best for patients and the
  public
• Overall, the skills of collaboration and
  integration in effective networks will be every
  bit as essential to local NHS hospitals as will
  the ability to compete.
• So must providers leave all this to commissioners
  alone?

23
Leadership

• Does leadership needs followership?
• Leaders (and followers) do not need to be always
  the same person
• High levels of oppositional behaviour imply that
  confrontation and criticism are valued more than
  creativity and risk taking

24
Clinicians

• Always laying claiming to ground they do not
  wish to occupy
• High levels of oppositional behaviour imply that
  confrontation and criticism are valued more than
  creativity and risk taking
• If you want to be valued make yourself valuable
• Learned helplessness
• On the pitch or in the stands?

25
Primary Care Reform

• GP contracts
• Quality and Outcomes Framework
• Pharmacists contract
• Nurse leadership (other clinicians)
• Practice Based Commissioning

26
Why PBC( Improvement Foundation)

• Improve services for patients
• Widen choice of providers
• Improve use of resources (reduce deficit!)
• Improve commissioning skills
• Reduce use of emergency care
• Improve clinical engagement
• Ensure ownership of patient use of services

27
Keeping it Personal

• Build on the best of traditional General Practice
• Primary Health Care more than general practice
• but registered population and 80 of all NHS
  clinical consultations
• 90 of care solely undertaken in primary care
• Support for self care
• Care Closer to home
• The practice can link the wider publics health
  and bio-clinical care

28
Clinical Case for Reconfiguration

• Specialist Centres significantly improve clinical
  outcomes in acute or critical care situations,
  such as heart attacks and stroke, trauma and
  emergencies, high-risk deliveries, and
  specialized paediatric care.
• Risks due to distance from the facility can be
  managed with better skilled first responders,
  such as paramedics.
• Local care (e.g., midwifery for uncomplicated
  deliveries) is more satisfying for non-critical
  care needs and does not consistently indicate
  poorer clinical outcomes than hospitals or
  specialist centres. In fact, patients seem more
  satisfied overall with the community-based
  services.

29

• Medical costs rise to equal the sum of all
  private insurance and Government subsidy
• Aaron Wildavskys
• Law of Medical Money

30
VFM

• Prescribing
• Out-patient care-follow up, new referrals
• Long term conditions management.
• Majority of hospital costs generated by the
  hospital

31
(No Transcript)
32
LTC

• 50 of people with LTCs have not been told about
  treatment options
• 25 do not have care plan
• 50 do not have a self care plan
• 50 medicines are not taken as intended.

33

• Personal health services have a relatively
  greater impact on severity (including death) than
  on incidence. As inequities in severity of health
  problems (including disability, death, and
  co-morbidity) are even greater than are
  inequities in incidence of health problems,
  appropriate health services have a major role to
  play in reducing inequities in health.

Starfield 12/03 03-385
34
Provider issues

• What is the usefulness of helping to bankrupt
  the funder?
• Collaboration can improve efficiency.
• Whether to compete or collaborate-the arbiter is
  assessing what would be best for patients and the
  public
• Overall, the skills of collaboration and
  integration in effective networks will be every
  bit as essential to local NHS hospitals as will
  the ability to compete.
• So must providers leave all this to commissioners
  alone?

35
Leadership

• Does leadership needs followership?
• Leaders (and followers) do not need to be always
  the same person
• High levels of oppositional behaviour imply that
  confrontation and criticism are valued more than
  creativity and risk taking

36
Clinicians

• Always laying claiming to ground they do not
  wish to occupy
• High levels of oppositional behaviour imply that
  confrontation and criticism are valued more than
  creativity and risk taking
• If you want to be valued make yourself valuable
• Learned helplessness
• On the pitch or in the stands?