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Primary Care in the United Kingdom Dr Mike Burrows Chief Executive Salford Teaching Primary Care Trust “adding life to ...

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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

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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

20

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 ƒAnti-Coagulation Services

ƒLearning Disabilities

ƒDrugs

ƒHPV Vaccination

ƒActive Case Management

ƒChildhood Vaccination & Immunisations

ƒNear Patient Testing ƒAccess/Extended Hours

ƒSafe Haven Service

ƒHeart Failure Services

ƒInfluenza & Pneumococcal Immunisations

ƒHomeless Services

ƒAlcohol Tier 1 (DES)

ƒMinor Surgery

ƒAlcohol Tier 2 (LES)

ƒOsteoporosis

ƒGateway Programme

ƒCardio-Vascular Disease

ƒEthnicity

ƒSmoking

ƒHealth Inequalities

ƒintrauterine contraceptive device (IUCD) Insertion

ƒPractice Based Commissioning

ƒIM&T

ƒChoice & 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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