Primary Care in the UK

What Can We Learn?

Cypress Health RegionSeptember 2004

Overview of the NHS

The National Primary Care Development Team

Launched in February 2000 by 4 people

Purpose was to establish the National Primary Care Collaborative

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.”

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

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

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

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

Healthcare Funding

Healthcare funding from Federal government

PCTs are focus of funding – receive ~75% of healthcare funding

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.

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

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:

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

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.

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

Example Practice Budgets

Practice Budget(£)

Year End

+/- % +/-

List Size

Drs A 697617 770879 73262 11 4497

Drs B 1478625 1549727 71102 5 11626

Drs C 481770 462737 -19033 -4 3316

Drs D 1263695 1214213 -49482 -4 9206

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)

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

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

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

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.

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

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

What Do They Do So Well?...(North Bradford PCT)

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

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

Successful Philosophies…

JFDI…

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

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

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

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

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

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

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…)

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

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

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

The 5 Simple Rules

1. See things through the patients’ eyes

2. Find a better way of doing things3. Look at the whole picture4. Give frontline staff the time and

tools to tackle the problems5. Take small steps as well as big

leaps

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

Final Thought…

“If you don’t take change by the hand, it will grab you by the throat”

-Winston Churchill