mind the gap - primary healthprimaryhealth.org.nz/plenarynickchamberlain.pdf · fee-for-service...
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Mind The GapDr Nick Chamberlain
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Domain Highest performer Lowest Performer New Zealand ranking (out of 11 countries)
1. Care process United Kingdom Sweden 3
2. Access to care Netherlands United States 7
3. Administrative efficiency
Austria France 2
4. Equity of care United Kingdom United States 8
5 Health care outcomes
Austria United States 7
OVERALL RANKING United Kingdom United States 4
Ranking of Health Care Systems,
Commonwealth Fund
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Drawn up by the International
Conference on Primary Health Care,
Alma-Ata,USSR, 6-12 September 1978Primary health care is essential health care based on practical,
scientifically sound and socially acceptable methods and technology
made universally accessible to individuals and families in the
community through their full participation and at a cost that the
community and country can afford to maintain at every stage of their
development in the spirit of self-reliance and self-determination.
It forms an integral part both of the country’s health system, of which
it is the central function and main focus, and of the overall social and
economic development of the community. It is the first level of
contact of individuals, the family and community with the national
health system bringing health care as close as possible to where
people live and work, and constitutes the first element of a continuing
health care process.
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The Primary Health Care Strategy
Hon Annette King, Minister of Health
February 2001
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• People will be part of local primary health care
services that improve their health, keep them well,
are easy to get to and co-ordinate their ongoing
care.
• Primary health care services will focus on better
health for a population, and actively work to reduce
health inequalities between different groups.
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Six key directions for primary health
care will achieve this vision:
•work with local communities and enrolled populations
• identify and remove health inequalities
•offer access to comprehensive services to improve, maintain and restore people's health
•co-ordinate care across service areas
•develop the primary health care workforce
•continuously improve quality using good information.
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Old NewFocuses on individuals Looks at health of populations as
well
Provider focused Community and people-focused
Emphasis on treatment Education and prevention
important too
Doctors are principal providers Teamwork – nursing and
community outreach crucial
Fee-for-service Needs-based funding for
population care
Service delivery is monocultural Attention paid to cultural
competence
Providers tend to work alone Connected to other health and
non-health agencies
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.
• The Strategy outlines a new vision for primary health care. It does
not contain details of implementation, which will involve
evolutionary change to protect the gains already made.
Involvement and collaboration with the primary health care sector
will be a key feature of the implementation process in the coming
months and years. This is crucial to ensure that all issues are
considered in developing the new arrangements.
• To achieve this involvement, working parties of providers,
communities, District Health Boards, and the Ministry of Health will
be formed around key areas of work. Consideration may also be
given to developing a primary health care advisory group to help
guide developments in the sector.
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Evaluation – Jackie Cumming
Primary Health Care Strategy had better integration as a key objective
• Reducing fees patients pay to improve access to PHC
• Development of Primary Health Organisations to co-ordinate care horizontally and vertically
• Strengthening role of PHC in the health system
• Encouraging team work and better co-ordination across providers
However, Primary Health Care Strategy:
• Seen to focus on development of new organisations (DHBs and PHOs) and population health focus
• Insufficient attention to service delivery and clinical integration
• Failure to identify what a comprehensive model of PHC might look like and how it might be delivered
• Failure to hold DHBs and PHOs accountable for delivering the strategy
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(‘Better, Sooner, More Convenient’)
Better Sooner More Convenient
“New models of care which see the patient rather than the
institution as the centre of service delivery and which aim to
promote a more seamless patient journey across community,
primary, and hospital sectors, greater use of primary and
community care, and the shifting of care ‘closer to home’.”
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Then There was IPIF – Integrated
Performance and Incentive Framework
So what was wrong with IPIF?
Nothing, absolutely nothing!
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System level measures
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NZ Health Strategy
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Primary Care Working Group report
• Funding - follow individual rather than practice
• Models of Care
• Workforce sustainability
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• Develop a Primary Care data and monitoring programme with
accountability for equity
• Primary Care Funding review - Funding follow individual rather than
practice
• Consolidated DHBs and PHOs - size allows both to take on more upside
and downside risk.
• Separate DHB dual functions of funder and provider
• New model of care - Updated Evaluation needed. Healthcare Homes
promising but primary secondary silos a limitation. Support financial and
org policies that bind together
• MOH - Develop implementation plan from the NZ Health Strategy with
specific outcomes. Improve engagement with sector
Primary Healthcare Evaluation - Amy
Downs (Fullbright/ Ian Alford Fellow)
supported by Treasury
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28
The Evidence Base for Primary and
Community Interventions
Note: many of these interventions are already underway across our Region in some form.
Ten evidenced-based community interventions to avoid hospital care
Hospital
activityQuality Cost
Hospital
activityQuality Cost
Improved GP access to specialists
including e-communication
Support for self-care for specific
conditions
Remote monitoring for certain long-
term conditions
Ambulance / paramedic triage to
community
Condition specific rehabilitationSupport to people in nursing / care
homes
End-of-life care in the communityExtensivist model for high risk
patients
Rapid access clinics for urgent
specialist assessmentSystematic Secondary Prevention
Key: Relatively good evidence that the intervention can do this Mixed evidence with studies coming to varying conclusions on this dimension
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29
A Health System for our Future
Populations
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• The Nuffield report “Shifting the Balance of Care” suggests new
ways of working in primary and community care to curb the growth
of activity in hospitals and other high cost per unit settings. These
include:
− Transferring certain hospital activities into primary and
community settings including people’s homes
− Utilising collaborative, multidisciplinary teams supported by
technology to provide alternative methods of consultation and
engage with patients, to empower them to take ownership of
their health and collaborate in the formation of their care
pathways.
• This approach has been found to:
1. Improve the productivity of primary care providers
2. Reduce pressure on GPs
3. Reduce unnecessary utilisation of health care services
Community vs. Hospital Investment
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Neighbourhood Healthcare Homes
Neighbourhood Healthcare Homes (NHH) are a collaboration
between NDHB and the Northland PHOs. The model is defined as:
“A team based health care delivery model led by primary care
clinicians that provides comprehensive and continuous health and
social care with the goal of supporting individuals to obtain
maximised, equitable health outcomes”
NDHB anticipates improvements in the areas of:
• Timely acute and unplanned care for patients
• Proactive care for high needs patients
• Excellent routine and preventative care
• Improved business efficiency.
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NHH Model Core Elements
• Call Management
• Clinical Triage (Right person, right day, right preparation)
• F2F for those who need it most
• Alternative options (Portal, Virtual Consults)
• Matching supply to demand
Timely Unplanned Care
• Standardisation, Visual Management, LEAN Flow, Continuous Improvement
Business Efficiency / LEAN
• Patient Register for those with complex needs
• MDT, Integrated Care planning approach
• Patient centred care, Multi Disciplinary meeting Proactive Care
• Proactive health plan for everyone – system initiated contact
• MCA pre consult work up
• Community Health Workers
• Telephony outbound campaigns
Routine Preventative Care
Q U A L I T Y & S A F E T Y
E Q U I T Y
Consumer
Engagement
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Quality and Safety in Primary Care
• What is Clinical Governance in General Practice/ Primary Care
• Who is accountable for Patient Safety and Quality in General Practice/ Primary Care
• “A marvel to get through the morning without any mistakes but a miracle to get through the afternoon as well”
• Don’t know error rates, but likely to be as high as 20%
• Adverse drug events are the fourth largest cause of admissions to ED in USA.
• Use of Global Trigger tools?
• Greater PHO accountability?
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Primary Care Strategy 2018
• Let’s not! We don’t need another Strategy. Learn from History,
revisit 2001, modernise it with a bit of BSMC and the NZ Health
Strategy, Working group recommendations, Primary Health Care
Evaluations, evidence of what works, and then this time, LET’S DO
THIS!
• National Consistency and Local Innovation
• An Implementation plan - a Portfolio with Programmes of work and
multiple Projects with resource for change
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Strategy is easy, Change and
Implementation is the hard part!