Re-organisation of Primary Care

Lyndon MilesChairman Gwynedd LHB

GP Bron Derw Medical Centre

Outline

Context, the wider NHS Improving Health in Wales Commissioning Primary care

– Optometry– Dentistry– Pharmacy– General Practice

Developing services locally

Context - “Traditional NHS activities”

Comprehensive “care delivery” Mortality falling, patients healthier New drugs and treatments Technological improvements Funding increasing All’s well?

– increasing demand – NHS failing to cope – WHY?– What’s happening to Health (rather than illness)

Inequalities in health – expectations of life

Men Women

1920’s 56 60

1930’s 59 63

1950’s 66 72

1990’s 74 79

Inequalities in health – unequal expectations of life

Men Women Female advantage

1920’s 56 60 3

1930’s 59 63 4

1950’s 66 72 6

1990’s 74 79 5

Inequalities in health – SMR’s

SC1 SCV Ratio V:I

1920’s 82 125 1.52

1930’s 90 111 1.23

1950’s 86 118 1.37

1990’s 66 189 2.86

Inequalities in health – mortality rates by economic activity

Activity Rates per 100,000

1971-79 1981-89

Employed 302 227

Unemployed 410 319

Death rate ratio 1.36 1.41

Inequalities in health – Direct age standardised rate ratios by housing and car ownership

Tenure Men Women

1971-81 1981-89 1971-81 1981-89

Owner-occupier

1.0 1.0 1.0 1.0

Private rent 1.32 1.38 1.32 1.38

LA tenant 1.35 1.62 1.42 1.44

1+ Cars 1.0 1.0 1.0 1.0

No cars 1.44 1.57 1.40 1.56

•Source: Whitehead M & Dahlgren G Inequalities in Health 1996

Examples of LA health related functions

Housing

Education

Economic and community

regeneration Leisurecycling,

swimmingplay spaces

Substance misuse

Environmental improvements

land use

YouthServices

Food safety

Sports facilities

EnergyEfficiency

Roadsafety

Air pollution

Communitysafety

HealthySchoolsSchemes

Publictransport

Employeeshealth

Partnership with Local Authorities

NHS problems

Demography Demand / waiting times / capacity to cope Increasing specialisation Rising standards Morale / HR issues Financial issues Chronic disease management !!!

Secondary care

System performance

Secondary care

Rising standards (investigations and treatments)

Secondary care

Rising standards (investigations and treatments)

Rising demand, falling prevention

Secondary care

Rising standards (investigations and treatments)

Rising demand, falling prevention

Dysfunctional system

How do we compare with other countries?

1 2 3 4 5 6 7 8 9 10

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Life expectancy x

Infant mortality x

Maternal death x

IHD SDR x

CVD SDR x

cancer x

External injury x

SDR RTA’s x

Suicide x

BestWorse

UK Relative to 18 European countries

Health Personnel – comparison with Europe

1995 (per 1000 population)

UK EU

Physicians 1.5 2.7

Dentists 0.4 0.6

Nurses 4.3 6.0

Country - spend on health care (% GDP)

Country UK France Germany 14 EU Countries

USA

% GDP 1997

6.8 9.4 10.7 9.0 13

% GDP 2001

7.6 9.5 10.7 9.2 13.9

1 2 3 4 5 6 7 8 9 10

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Life expectancy s x

Infant mortality s x

Maternal death s x

IHD SDR s x

CVD SDR s x

cancer s x

External injury x s

SDR RTA’s s x

Suicide x s

Best Worse

SWEDEN (UK) Relative to 18 European countries

Ranking of Health System Performance 2000 (WHO)

France 1st

UK 18th

Germany 25th

USA 37th

NHS national solutions

Focus on health Job evaluation New contracts Re-organisation to improve efficiency

Better Health, Better Wales

Life expectancy in Wales 3-4 years less Life expectancy (valleys) 5 years less Infant mortality, heart disease, cancers,

LT illness all worse

Improving Health in Wales

Reorganisation of structures New accountability arrangements Focus on partnership working Needs led / clearer mechanisms County HSC&WB Strategies

LHB Functions

Corporate and Clinical Governance Securing and Providing Primary &

Community Health Care Services Securing Secondary Care Services Improving the health of communities Partnership Public Engagement Provision of services

Healthcare Commissioning

Needs assessment

Address problems Service delivery analysis

Review performance Consider professional and commissioning plan / WAG guidance and

views of clinicians & patients & stakeholders,

Executive engagement Develop service commissioning with providers plans (including resource implications, public consultation if necessary)

Care pathway analysis

Consider patient’s journey through system Allows holistic analysis, not organisational

needs Identifies blocks, delays, inefficiencies,

duplications etc Should improve patient experience and

improve NHS efficiency

Primary Care

Optometry Dentistry Pharmacy General Practice Diagnostics Estates IT

Optometry - “The Future of Optometry Services in Primary Care in Wales”

Developed role – detection pathology / referral / monitoring– therapeutic treatment– Over 75 assessment / driving– Children– Specialist contact lens work– Occupational / sport eye care

Schemes– Cataracts; glaucoma; low vision; minor problems etc

Professional development IM&T, Premises, workforce planning

Dentistry – “Routes to Reform”

Mixed economy Currently: Dental health worse than England; decline in

children disappointing; marked inequalities; adults retaining teeth longer

Challenges: High restorative need; new approaches to children; action re inequalities; fluoridation

New Dental Contract LHB commissioning / local dental action plans 17% increase in training places in Wales Dental grant schemes

Pharmacy – “Remedies for Success”

Need for integrated strategy Vision = co-ordinated service helping people to:

– Maintain health– Manage common ailments– Best use of prescribed medicines– Manage long term medication needs

Re-designing services Making best use of resources

Information Technology“Informing Healthcare”

Single electronic record– Confidentiality project

Workforce empowerment Patient and carer empowerment Service improvement Knowledge and information management

General Practice

“The Future of Primary Care”– All primary and community based– Patient and public involvement (joint LHB / LA action)– CHC have statutory inspection rights over primary care

(NHS Wales Bill – as from 1/4/04)– Address disadvantaged groups (through SAFF process)– Recognise work towards health (HLC’s, H. Alliances)

nGMS contract

nGMS contract

http://www.visualproductions.co.uk/new%20contract/hh_start.htm

Practice based contract Out-of-hours opt-out LHB commissioning Clinical governance / Chronic Disease management /

organisational monitoring IT New GP Career structure

Changes to GP

Chronic disease clinics Local additional / enhanced services e communications

– Prescribing, dispensing, x interfaces, paperless, single records

Resource centres Links with SS / care assessors / unified

assessments Pathway developments Referrals analysis

What’s happening in Gwynedd?

OOH Additional / enhanced Care pathways Extending roles within practices Promotion of primary care teams Estate strategy ?? Resource centre

Task?

Advise on how a clinical service might be re-designed?– Agree which service (pick one that involves

crossing boundaries)– Consider patient’s pathway– Any blocks / delays / skill-mix– Resource neutral (or limited)