Primary Care in the UK

1. Primary Care in the UK What Can We Learn? Cypress Health Region September 2004

2. Overview of the NHS

3. The National Primary Care Development Team • Launched in February 2000 by 4 people • Purpose was to establish the National Primary Care Collaborative

4. 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.”

5. National Primary Care Collaborative • 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

6. Initial Focus of the Collaborative • 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

7. After Only Two Years… • 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

8. By March 2003, the Collaborative involved over 2000 practices serving almost 11 million patients, making it the largest health improvement program in the world.

9. Healthcare Funding • Healthcare funding from Federal government • PCTs are focus of funding – receive ~75% of healthcare funding

10. 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. • 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.

11. Primary Care Trusts (PCT) • Equivalent to SK Health Regions • Local health organizations responsible for managing local health services • 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. • Work with local authorities and other agencies that provide health and social care to ensure community’s needs are being met • Because they are local organizations, they are in the best position to understand and meet needs of the community

12. How the Money is Spent… • 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:

13. Secondary Care Funding • Hospital and Specialist Services: • purchased on a contract basis • the number of needed services (ex: 700 hip replacements) are estimated at the start of each budget year. • If additional services were required by year-end, the difference is paid to the provider by the PCT

14. 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.

15. Primary Care Funding • GP services • 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 • Each practice decides how to use this money to best serve their patients, and meet the NHS and PCT targets for healthcare • Many practices employ nurses and other healthcare professionals to provide a variety of services for their patients. • Budgets must also include drug costs for all medications prescribed by the GPs

16. Example Practice Budgets

17. Incentive Schemes • 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)

18. 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

19. Examples of Incentive Targets • 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

20. Primary Care Funding • Nursing Services • home care and public health nurses employed by the PCTs. • Practice nurses (Nurse Practioners), located in GP practice are employed by each individual practice

21. Primary Care Funding • Pharmacy Services • 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.

22. Pharmacy Services • 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

23. What Do They Do So Well?...(North Bradford PCT) • Positive attitudes toward healthcare by all involved • Excited about what has been accomplished and what can yet be done • Pride in their work • Willingness to embrace change

24. What They Do So Well…(North Bradford PCT) • Information and experience sharing throughout the NHS and PCTs • Not satisfied with the status quo • Constantly looking for innovative ways to improve healthcare • Majority of top executives are still front-line workers

25. Successful Philosophies… • 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 • 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

26. Successful Philosophies… JFDI…

27. Key Concepts We Can Learn From… • Support for all levels of healthcare from management/government • Accountability on all levels • Adaptability to change • Work with early adopters • Power given to frontline workers • Many top execs are still frontline HCPs

28. Advanced Access • Restructuring of services provided and work flow in physician practices have resulted in: • 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

29. Advanced Access • Requires no additional funding • Efficient provision of healthcare • Patients receive care from the most appropriate health care professional • Relatively simple to incorporate • Patients & Physicians/HCPs benefit • HQC initiative • Providing support for interested practices

30. Alternative Physician Reimbursement • 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

31. Greater potential earnings for physicians • entice new practioners • Physicians have more control over their practice • In the best position to determine which services are needed to serve their patients • Work with early adopters • Successful SK practices are best evidence for future adopters

32. Focus on Primary Care… • Uk system has realized that it is more efficient to spend money on 1o care rather than 2o care • 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

33. Empower Healthcare Professionals • Allow front-line workers the ability to develop and implement change • 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…)

34. Private Healthcare Providers • 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

35. Challenges For Us… • Healthcare provider attitudes • Patient attitudes • Unions • Funding (provincial vs federal) • Lack of resources (human, financial) • History of extensive committee decision making • Slow implementation of change and development

36. Challenges… • Resistance to change • Fear of failure • Tendency to try to implement major change rather than focusing on small continual changes • Lack of IT systems

37. The 5 Simple Rules • 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

38. The 3 R’s • 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

39. Final Thought… “If you don’t take change by the hand, it will grab you by the throat” -Winston Churchill