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

• 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

• 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– 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

Pharmacist

Community nurse

Optician

Dentist

Complementary practitioner

Patient

Primary care physician

Practice nurse

Physician with expertise in headache:

GP; PCT; specialist

Ancillarystaff

Primary care Specialist care

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:– 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

• 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