Primary Care
“That aspect of a health services that assures person
focussed care over time to a defined population,
accessibility to facilitate receipt of care when it is first
needed, comprehensiveness of care in the sense that
only rare or unusual manifestations of Ill health are
referred elsewhere, and coordination of care such that
all facets of care (wherever received) are integrated.”
Starfield, B. J Epidemiology and Community Health 2001; 55:452-4
General Practice in England
• In 2002 the Audit Commission published A Focus on General Practice
in England. They reported;
“General practice is an important service, accounting for eight out of ten
patient contacts with the NHS, but only one-fifth of NHS spending (£8.3
billion). Most people see the GP as the first port of call when they are
feeling unwell and 99 per cent of the population are registered with a GP,
usually close to where they live. General practice is highly rated by the
public and evidence shows some overall improvement in quality.”
• The c.8,500 practices in England deliver 314m consultations each year
(Healthcare Commission “State of the Nation” Report 2006). This
represents an average 6 per year for each person or 720 weekly by each
practice.
• There were 30,358 GPs in September 2003, and 33,091 in September
2006.
QOF
The Quality and Outcomes Framework was the first example
of its kind in the world, introducing a dramatically more
systematic focus on evidence-based care.
95
100
75
79
72
58
50
41
43
30
25
0
AUS
CAN
GER
NETH
NZ
GPs are ahead of family doctors in
comparator countries in uptake of
financial incentives for quality, IT use
and chronic disease management
UK
US
Percent receive
financial incentive:
AUS
CAN
GER
NETH
NZ
UK
US
Achieving certain
clinical care targets
33
10
9
6
43
92
23
High ratings for
patient satisfaction
5
—
5
1
2
52
20
Managing patients
with chronic disease/
complex needs
62
37
24
47
68
79
8
Enhanced preventive
care activities
53
13
28
18
42
72
12
Participating in
quality improvement
activities
35
7
21
28
47
82
19
Source:
2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
Recent research has shown that care for some chronic
conditions improved more rapidly when QOF was introduced,
although subsequent gains have been more difficult
•The rate at which quality was
improving increased for asthma
and diabetes immediately
following the introduction of the
scheme
•The rate of improvement
continued for coronary heart
disease at the same rate as
before the scheme
•In subsequent years, the rate of
quality improvement appears to
have slowed down
•QOF needs to be continually
reviewed in order to support
optimum health outcomes for
patients
Source: Campbell SM et al; National Primary Care Research and Development Centre
However, there have been criticisms of early QOF that its
clinical indicator set didn’t correlate well with possible
population health gains
•
QOF indicators are not optimally
aligned with interventions and
activities that will have the maximum
impact on population health
•
Cookson et al* correlated evidence on
the population health gains from
cardiac prescribing interventions with
the relevant QOF payments
•
Plotted points associated with these
interventions against likely lives
saved p.a. per 100,000, with a
relatively poor fit.
Source: Fleetcroft, R. and Cookson,, R. (2005) Do the incentive payments in the new NHS contract for primary care reflect likely
population health gains? Journal of Health Care Research and Policy
The incentives in the Quality and Outcomes Framework for evidence
based quality care are predominantly focused on diagnosis, management
and secondary prevention of long term conditions.
Everyday
activity
Some primary prevention activity clearly takes place in GP
practices, but there is no systematic framework for ensuring
that people who need it have access to it or for measuring
quality.
Preventio
n points
Only 7.5% of the QOF is dedicated to health promotion/illness
prevention, covering:
• registers for obesity and learning disability
• recording blood pressure and smoking status
• having a stop smoking strategy.
• for 2009/10: CVD primary prevention and sexual health
QOF 2009/10
Mostly
disease
manageme
nt
Primary prevention
Disease management
Organisational
Patient Experience
8
Proposed scope and frequency of review
‘flu indicators
Advice from JCVI
Indicators out of scope
Indicators within scope
Organisational indicators
RCGP practice
accreditation
Patient experience
indicators
Disease management and
secondary prevention
(excluding flu indicators)
GP patient survey
Primary prevention and
health inequalities
Frequency of output for indicators
managed by NICE:
•to review all 88 indicators in 3-4 years
(20-30 per year)
•cost effectiveness evidence for an
additional 10 indicators per year
Local flexibility
Rationale
for local
indicators
There may be a high prevalence of certain diseases within a
PCT that is not representative of the general population
- eg HIV in Southwark, London
Current
barriers to
uptake
•need for technical expertise in the development of evidence based
indicators;
•IM&T support required to extract data from clinical systems and to link
this with payment calculations.
•no national decisions to set aside part of the £1 billion national
investment in QOF for local investment.
Menu of
QOF indicators
Solution
QOF indicators
______ ______
______ ______
______ ______
% for national use
% for local use
NHS Employers consult GPC
The NHS and Social Care
Long Term Conditions Model
Better outcomes
Community
Resources
Case Management
Empowered and
informed patients
Decision support
tools and clinical
information system
(NPfIT)
Health and social
system environment
Disease
Management
Supported
Self care
Promoting Better
Health
Creating
Delivery System
Supporting
Infrastructure
Prepared and
proactive health and
social care teams
CQUIN
•
The Commissioning for Quality & Innovation (CQUIN)
scheme has been introduced to ensure organisations pay
a higher regard to quality by making a proportion of a
provider’s income conditional on quality and innovation.
Commissioners will agree with their providers, the areas
of service to be subject to a CQUIN scheme.
•
For the current year 2009/10, commissioners have the
option of implementing a full CQUIN scheme with their
community providers or a more limited scheme linking
payment to an agreed quality improvement plan. The
latter recognised the importance of establishing a good
baseline for monitoring quality.
•
A full CQUIN scheme will be mandatory for all
community providers from April 2011.
NHS Next Stage Review (Darzi) Final Report
Personal Health Budgets
•
The pilots will test a range of models of personal health
budgets: this is not necessarily about a direct cash payment
(although we are bringing forward primary legislation so
we can test that), but could include people simply being
aware of the choices available to them within a notional
budget or through a budget held by a third party.
• Personal health budgets will not be suitable for all types of
care or for all patients, but they have the potential to be one
of the levers that drives the much wider cultural change we
are aiming for.