Primary Care in the United Kingdom Dr Mike Burrows Chief Executive Salford Teaching Primary Care Trust
“adding life to years and years to life IN Salford”
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Primary Care Background • United Kingdom four separate healthcare systems • England – 152 Primary Care Trusts
• A financial allocation direct from central government • PCTs – Commissioning of services – Provision of services – Public Health role 2
Where is Salford?
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Salford
• 230,000 population • A post industrial city • 35% of ward areas are in the 10% most deprived in the country • PCT co-terminous with local government
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Salford – Male Life Expectancy 78 77 76 75 74
Years 73 72 71 70 69 68 1995/96
2002-04 Salford
2003-05
2004-06
England 5
Salford – Female Life Expectancy 82 81 80 79
Years
78 77 76 75 1995/96
2002-04 Salford
2003-05
2004-06
England 6
Salford – A Few Health Statistics Standardised Mortality Ratios (SMRs) • Heart Disease & stroke in under 65s – 151 • Stroke – 137 • Cancers – Colon – 126 – Lung – 180 – Oesophagus – 153 – Stomach – 132 • Anti-depressants 1/3 above national average
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Primary Care in Salford
• 53 GP Practices • 155 doctors • Practices – Separate organisations – Partnerships or sole traders
• Contractual relationship with the PCT as commissioner 8
Features of the GMS Contract
• Core contract based on population size • Performance based component – 3 domains • Clinical • Organisational • Patient experience
• Specific funding for additional services – National – Local 9
Quality & Outcomes Framework (QOF) Clinical Indicators Secondary prevention of coronary heart disease Cardiovascular disease – primary prevention Heart failure Stroke and Transient Ischaemic Attack Hypertension Diabetes mellitus Chronic obstructive pulmonary disease Epilepsy Hypothyroid Cancer
Palliative care Mental health Asthma Dementia Depression Chronic kidney disease Atrial fibrillation Obesity Learning disabilities Smoking
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Quality & Outcomes Framework (QOF) clinical domain examples • Percentage of patients with coronary heart disease in whom the last blood pressure reading is 150/90 or less • Percentage of patients with coronary heart disease whose last measured total cholesterol is 5mm/l or less • Percentage of patients with hypertension in whom the last blood pressure reading is 150/90 or less • Percentage of patients with diabetes in whom the last blood pressure reading is 145/85 or less • Percentage of patients with diabetes in whom the last HbA1c is 7.5 or less 11
Quality & Outcomes Framework (QOF) Organisational Domain •
Records and information
•
Information for patients
•
Education and training
•
Practice management
•
Medicines management 12
Quality & Outcomes Framework (QOF) Patient Experience Domain
•
Length of Consultation
•
Access to a Primary Care Professional within 24 hours
•
Access to a GP within 48 hours
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10 10 01 0 0 20 20 01 00 30 30 01 00 40 40 01 00 50 50 01 00 60 60 01 00 70 70 01 00 80 80 01 00 90 - 9 01 00 0 10 - 1 00 00 0 1 11 - 1 0 00 10 00 1 12 - 1 00 20 00 1 13 - 1 00 30 0 1 -1 0 40 00
0
Frequency
Analysis of GP Practice Size in Salford
14
12
10
8
6
4
2
0
Number of Patients 14
Number of GPs within Each Practice 20 18 16
Frequency
14 12 10 8 6 4 2 0 1
2
3
4
5 GPs
6
7
8
9
15
00
0
-7 50
00
50
-5
-1
0
0
-2
00 0 -1 12 2 50 50 15 15 00 00 17 17 50 50 20 20 00 00 22 22 50 50 25 25 00 00 27 27 50 50 30 30 00 00 32 32 50 50 -3 50 0
10
75
50
25
0
Frequency
List Size (Number of Patients Per GP)
10
9
8
7
6
5
4
3
2
1
0
Patient Numbers
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Patient Numbers 3250 - 3500
3000 - 3250
2750 - 3000
2500 - 2750
2250 - 2500
2000 - 2250
1750 - 2000
1500 - 1750
1250 - 1500
1000 - 1250
750 - 1000
500 - 750
250 - 500
0 - 250
Frequency
List Size (Number of Patients Per GP)
10
9
8
7
6
5 > 1 GP
4 Single GP
3
2
1
0
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QoF Points – Performance of Salford GPs
Domain Clinical
Maximum Available Points 2008/09
Points Achieved 2008/09
% Points Achieved 2008/09
36,400
32,883
90.34%
Organisational
9,380
7,785
82.99%
Additional services
2,016
1,724
85.53%
Patient experience
8,204
6259
76.29%
56,000
46,242
82.58%
Total
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Gore H Dr C Leac how hG dhur y(Je et II) D avis Borg Ws -Cos tanz i Jm Lara h Dg Sinh a Rp Leve nson S Rolf e Jn Drs Nage Tauk sh & T Chila mku rthi Sulta nM Salim Rahm A an A Elem ent P Boyc Salfo e Ct rd C are C Finegan N entre s We a aste Buch Kh Sing h Hs Warb Salfo urto rd H n ealth Matt ers Ahu ja A Brow n e Mcc Nb orkin dale S Colli er Jeet I Lind say Sd Yate s Ms Tam kin E j Shar ma M Malc m oms on C i Kass am N n Sing hH Habe rS Khan Mt Dr A min Kyaw T Hop eB Dr L oom ba Josh iV Marg inso n Je Dr B udde n Rand all S c Tank el Jw Sted man Hgb Kori aK Tyrr ell N m Allw eis B Gho sh P r Saxb yK
Locu m To
Achievement
% Exceptions % Not Achieved % Achieved % Actual prevalence Average Achievement
80%
70%
60% 6.00%
50% 5.00%
40% 4.00%
30% 3.00%
20% 2.00%
10% 1.00%
0% 0.00%
Practice Name
19
Prevalence
% of patients with Coronary Heart Disease whose last measured total cholesterol (measured in the previous 15 months) is 5 mmol/l or less.
Coronary Heart Disease 8 2008/09
100% 10.00%
90% 9.00%
8.00%
7.00%
D rs
A Gore H Nage Sult sh & Chila an M mku rthi L e ach Borg G - C os t a nz i Jm T a uk T D avi s Ws La r a Salfo h Dg rd C a r e C D r Loo m ba e n t re s We aste Je et I H a be r S Le v e ns o n S B oy c e Ct Locu Dr A min m To Dr C Colli ho w er dhur y (J e et II) T a nk el J w Salfo Ta m kin E rd H ealth j Matt er s J os h iV Rolf e Jn Sing h Hs Malc om s o n Ci M a rg inso n Je R a nd all S c Elem en B r ow t P ne N R a hm b an A Warb u rt o n Gh o sh P r K ori aK St e d man H gb Fine g an Na Shar ma M m K a ss am N n Sinh a Rp S i ng hH B uc h Kh Saxb M cc y K orkin dale S H op eB K y aw T K ha n Mt Ty r r ell N m A hu ja A Allw eis B Lind say Sd Dr B u dde n Yate s Ms
Salim
Achievement
% Exceptions % Not Achieved % Achieved % Actual prevalence Average Achievement
70%
60% 6.00%
50% 5.00%
40% 4.00%
30% 3.00%
20% 2.00%
10% 1.00%
0% 0.00%
Practice Name
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Prevalence
Diabetes Mellitus 12 2008/09
% of patients with Diabetes in whom the last blood pressure was 145/85 or less
100% 10.00%
90% 9.00%
80% 8.00%
7.00%
L e L ea ve c h n G S i so n nh S D a Br r A Rp ow m i D a ne n vi N b Su s W lt s R o an l M Bu fe J ch n Bo Sa K F rg i n li h - C eg m os an A ta N n B o zi J a yc m G eC or t e Sa Ra Co H lf o l n rd d a l ie r H ea Jo ll S l th s c M hi V at te E l T a u rs em k en T M t ar gi Je P ns et Al on I lw J e e Ho is B La pe W ra h B ar D b Sa Ya urt g l fo te on M s rd a K lc o M s Ca o re m ria Ce T s o K nt am n C r S t es k i n i ed W E j m ea a n st e Ha Hg S i be b ng r S h B S h u Hs ar d d Ka m a en s M D r sa m m Lo N Lo o n S a mb cu x a m Kh by To K Dr Ta an Ch nke M t o l L i w d Jw nd h sa ury Dr Ah y S s Ra u d N a g M T h m ja A e s c yr an h c o re A & r k ll Ch in Nm i la d a l m e G ku S h o rt s hi Ky h P r S i aw ng T h H
Total Points
Salford PCT - Practice Points Achievement 2008/09 PATIENT EXPERIENCE PATIENT EXPERIENCE ADDITIONAL SERVICES ADDITIONAL SERVICES ORGANISATIONAL CLINICAL
1000
800
600
400
200
0
All single GP practices Practice Name
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Enhanced Services Anti-Coagulation Services
Learning Disabilities
Drugs
HPV Vaccination
Active Case Management
Childhood Vaccination & Immunisations
Near Patient Testing Access/Extended Hours
Safe Haven Service
Heart Failure Services
Influenza & Pneumococcal Immunisations
Homeless Services
Alcohol Tier 1 (DES)
Minor Surgery
Alcohol Tier 2 (LES)
Osteoporosis
Gateway Programme
Cardio-Vascular Disease
Ethnicity
Smoking
Health Inequalities
intrauterine contraceptive device (IUCD) Insertion
Practice Based Commissioning
IM&T
Choice & Booking 22
Other Contractual Arrangements
• Personal Medical Services Contracts (PMS) – Locally negotiated – Based on GMS Contract
• Equitable Access – Tendered Contract, open to competition – 3 – 5 year contracts 23
The GMS Contract – Key Points To Reflect On
• • • • •
Based on need Clinical good practice incentives Flexibility in the way it can be delivered Encourages larger group practices Local tailoring via LESs
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The GMS Contract – Key Points To Reflect On
• Contract in perpetuity • Clinical quality must be a process of continuous improvement • Negotiated with a powerful body • Doctors as practice mgrs with salarieds • The single hander “problem” • Limited use of flexibilities 25
Suggested Areas of Improvement • Targets should be more and more challenging • Percentage of income within QoF should increase • Patient choice should be encouraged • Good practice / innovation in contract use should be encouraged
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