The Primary Care Home
Professor David Colin-Thomé
Independent Healthcare Consultant
david@dctconsultingltd.co.uk
www.dctconsultingltd.co.uk
The Primary Care Home
• All providers need to also define a population responsibility if they
are to be a more influential and proactive organisation. This is of
particular import to improve the care of people who have a long term
condition.
• Future care will inevitably be more integrated and overtly
accountable, much more based in community settings and optimally
delivered if chiefly responsible for a defined population.
• Hence the concept of the Primary Care Home, a community based,
integrated, accountable home for population care where the needs
of the individual and of the community can be met. Served by an
holistic budget that enables a ‘make or buy’ approach to care
delivery and commissioned by the statutory commissioner(s)
Building on the past
Primary Care
• ‘soul of a proper, community orientated, health-preserving care
system’. Berwick DM. A transatlantic review of the NHS at 60. BMJ
2008;337:a838
• “The well known but underappreciated secret of the value of primary
care is its person and population, rather than disease, focus”
(Starfield, 2009,).
• “There is lots of evidence that a good relationship with a freely
chosen primary-care doctor, preferably over several years, is
associated with better care, more appropriate care, better health,
and much lower health costs.” Starfield
• The ability to “organise the chaos of the first presentation’. Paul
Freeling late emeritus Professor of General Practice
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
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Benefits;
Higher patient satisfaction with health services
Lower overall HS expenditure
Better population health indicators
Fewer drugs prescribed per head of population
The higher the number of family physicians the lower the
hospitalisation rate.
General Practice
Wilson T, Roland M, Ham C. The contribution of general practice
and the general practitioner to NHS patients, J R Soc Med 2006;
99:24–28
We identify three areas in which British general practice performs well, leading
both international policy analysts and the public to their favourable conclusions:
Equity
Quality
Efficiency
And three important characteristics that contribute to this success:
Co-ordination
Continuity
Comprehensiveness
Primary and community care strategy:
overview
Case for
change
Our
vision
Leading
local
change
Strengths
Highly valued
services
Ties to local
communities
A decade of
improvements
Challenges
Services that don’t
join up
Unwarranted
variability in quality
Changing
demands
Services shaped
around individuals
Promoting healthy
lives
Continuously
improving quality
Responsive and
integrated care
Choice in primary
& community care
Empowered
patients & public
Promoting health
throughout life
Access to healthy
living services
Tackling health
inequalities
Reinvigorating
PBC
Transforming
Driving continuous
community services
improvement
Piloting integrated
services
World class
commissioning
Assuring essential
standards
Health and social
care
It is the unique attributes of the GP system that has
lent itself well to being the central plank of post 1990
English NHS reform.
• GP Fundholding where budgets could be allocated to a GP practice
population and not tied to a specific disease or care group. This
allowed an opportunity for a more imaginative use of the monies to
provide better care for their patients.( Julian Le Grand,
Nicholas Mays, and Jo Mulligan (1998) (eds) Learning from the
Internal Market: a Review of the Evidence. London, Kings Fund).
• The Quality and Outcomes Framework which is the largest pay for
performance system for clinicians world-wide and can only be
successfully delivered to a defined population.
• And in 2013 the General Practice led Clinical Commissioning
Groups that will replace the current Primary Care Trust managerially
led commissioners. The Groups will receive their monies based on
aggregated practice list based allocations and every GP practice will
have to be a member .
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NHS Reforms England
Shapiro, Colin-Thomé, Mulla. BMJ May 2011
• Although the current English NHS reforms have been
developing over two decades, their direction has been
remarkably consistent.
• Three basic elements have emerged: the separation of
provision from procurement (to try to reduce the acute
sector’s supply side pressures on demand); the introduction of
some contestability to further reduce complacency among
providers; and the devolution of decision making more closely
to the patient interface to increase clinicians’ personal
involvement in these decisions.
• Naturally, the mechanisms have changed and evolved but the
underlying principles have weathered changes in government,
health secretaries, and financial circumstances. Indeed similar
principles have underpinned health service reform
internationally.
Improving on the present
Improving the quality of care in general practice
Report of an independent inquiry commissioned by The King’s Fund 2011
• ‘What my colleagues and I are anxious to say here is that the study
of quality in general practice is an underdeveloped area. Many
reasons might be offered. One which comes through clearly is that,
for many in general practice, it is not an area of health care greatly
given to self-reflection and self-challenge’
• Quality extends to the way in which all types of teams work for the
benefit of patients and the wider public.
• Surveys show that public satisfaction with the NHS is higher than it
has ever been and that general practitioners and other primary care
staff enjoy high levels of trust and confidence from patients.
Improving the quality of care in general practice.
Report of an independent inquiry commissioned by
The King’s Fund 2011
• There was relatively little information on the quality of general
practice and no comprehensive overview
• The evidence brought together in this report shows that while
standards of general practice are generally high, there are no
grounds for complacency. On many of the available indicators, there
are variations in performance, suggesting that more needs to be
done to realise Nye Bevan’s vision that the NHS should ‘universalise
the best’.
• The panel quite rightly emphasises the role that practices
themselves have in tackling variations in the quality of general
practice and in creating an environment for quality improvement
• It is not clear whether action by general practice will be sufficient.
Like other professions, general practice includes conservatives as
well as innovators..
The Medical Home
• In the USA over many years has seen a focus by some
health care leaders to fashion a system for co-ordination
of care out of their country’s non- system approach to
health care delivery. The concept of the ‘Medical Home’
is such an approach discussed for some thirty years.
• Of course some notable USA ‘meso’-organisations have
developed outstanding system approaches; Kaiser
Permanente, the Veterans Health Administration and so
on.
• .
USA Healthcare Reform
• President Obama with his reform programme is attempting in an
often hostile environment to bring some national system approaches
to bear on the wider health care service via organisational models.
His National Protection and Affordable Health Act includes the
concept of Accountable Care Organisations
• So what of the UK? Where is our ‘Medical Home’? And our
‘Accountable Care Organisation’? To me even if not universally
acclaimed as such, it already exists - it is list based general practice
where primary care workers combine one to one personal care with
the potential of population care. The success of general practice in
the UK is based on continuity of care serving a practice population.
Good general practitioners have the on-going trusting relationship
with and a responsibility for their patients even when those selfsame patients are not ‘in front of them’
Creating a sustainable local future
Key elements of Liberating the
NHS
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Create a patient-centred NHS
Focus on improving their experience and their health outcomes
Empower professionals – end top-down control
• Or put another way
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No decisions about me without me - an information revolution
arming patients and clinicians with more transparent data, helping
patients to make more informed choices and hold the NHS to account.
•
Outcomes that are amongst the best in the world – a shift to a
future focussed on better outcomes and away from structures and
process.
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Empowering clinicians to deliver results – setting them free to make
decisions for their patients, for example GPs commissioning services
for their local communities.
A New NHS Commissioning
• Being the ‘people’s organisation’,
• new relationships with the wider health eco system,
• the healthcare system leader ensuring qualitysafety, effectiveness and patient experience and
equally to promote and deliver on innovation,
prevention and productivity delivered by providers.
• So a key fourth domain is a new and essentially a
completely new relationship with providers of care
NHS Healthcare Commissioning is all
about good provision
• From a strictly NHS focus, commissioners must be about ensuring
good provision of care. Key ‘design principles’ essential to improve
health and healthcare are
• - integrate care, in its widest sense, including social services and the
voluntary sector.
• - level up general practices to reduce 'unwarranted' variation
• - redesign pathways so that care is delivered 'closer to home',
reducing the system's current dependence on hospital in and outpatients.
• - put in place targeted prevention programmes that addresses the
needs of the population
NHS Healthcare Commissioning is all
about good provision.
• Commissioner is the system leader-as the funder and as the
‘organisation of the people’
• Clinical Commissioning Groups align the incentives
• Care can only be improved if the ‘flow’ of care is optimal;
- more care in community settings,
- better integrated referral
- hospital as a flow system
- integrated discharge- most after care only in community settings
• Where is the provider leadership for the ‘system’ or do they prefer to
be a parallel universe?
• The providers should undertake much of the work currently
undertaken by commissioners
• Primary Care provision needs to expand its scope and
responsibility.
• Hospital or other providers as a principal provider
Long Term Conditions
• Nowhere is the coming together of individual and population needs
more important than for serving those patients and individuals with
long term conditions.
• And nowhere is there a more urgent need for organisational
leadership. There are many imperatives if we are to deliver a quality,
equitable and cost effective service. This applies to all services but
the care of those with long term conditions in particular those who
have co-morbidity of conditions and especially those who also are
frail and elderly should serve as a template, an exemplar and an
accountability of NHS.
• For most patients, all of their care can be provided in the community
• Delivery will depend on the NHS providing optimal care but many
facets of the strategy are also for the wider public health eco system
and its system wide accountability. NHS commissioners as must all
statutory bodies, need to exhibit a leadership beyond their own
remits and specific responsibilities.
GPs in the new world
• Could have multiple roles- all equally important;
• As leaders of consortia-as in a proactive board of an organisation.
Setting the culture and style and providing knowledge on a range of
clinical issues-both quality and cost effectiveness
• As executives of the consortia-CEO, MD etc
• As designers and leaders of specific care pathways for the
consortium
• Ensuring their practices are high quality, responsive and cost
effective organisations
• As excellent individual generalists who offer continuity of care
Primary Care Provision
• Individual Practice
• Federated Practices
• New population based MCOs- horizontal and/or vertical.
The Primary Care Home
• And in the future?
• New niche providers
• ‘Disruptive’ technologies leading to a new approaches to
provision
Primary Care Home
• All primary care contractors apart from some of the ‘corporates’
however large within their professional ambit are small in NHS
terms. The Royal College of General Practitioners promoting of GP
Federations offers the opportunity for primary care professionals and
their staff to remain local and retain the uniqueness of their current
organisations. Yet concomitantly have an overarching organisation
for activities that require a more centralised headquarters like
function.( BMJ 335 : 585 doi: 10.1136/bmj.39342.589294.DB
(Published 20 September 2007)
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• But the Primary Care Home offers more. A chance for professionals
to integrate when that is necessary to increase their range of
activities. And also to be part of an organisation real or virtual that
can deliver on the potential of community based professionals by
being an holistic resource for their community.
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Integration is about relationships
• The Primary Care Home will not succeed if this is perceived as a
GP takeover. All professional skills are required if we are to improve
on the often disappointing outcomes that the NHS currently
provides.
• “Primarily integration is about relationships between people. These
relationships are not informal friendships. They have to be worked
on and built professionally if clinical integration is to be meaningful
and sustained through good and bad times. (C Ham. Competition
and integration in the English National Health Service BMJ
2008;336:805-807.doi:10.1136/bmj.39532.445197.AD)
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Integration
• There are many forms of integration with mixed evidence that
integration can produce better care(Ramsay, A., Fulop, N.
and Edwards, N. Journal of Integrated Care 2009, vol 17(2): 312.).
• The chief potential downside of integrated organisations is the
strong possibility of ‘provider capture’ that will lessen choice and
responsiveness for their citizens. At the very least such
organisations must offer their public and patients choice outside of
and within their services and constituent practices. That offer must
be overtly transparent.
Accountability
• Such community based organisations would be commissioned by
the statutory NHS commissioner or indeed statutory commissioners.
The NHS and Local Authority working together whether for
healthcare alone or preferably also for social care. Indeed for the
broader public health aspects of the whole local authority.
• Accountable to their commissioner but transparently working with
and accounting to their population. That being the bulwark against
provider capture.
• A good adage for the NHS is maybe worry less about making people
accountable and more about how to help them feel responsible
Primary Care Home
Which population do they serve?
• The services offered by such an organisation must be left to local
choice so an organisation could be actual or ‘virtual’.
• Similarly with their defined population. The most straightforward
approach is for it to be based on the GP practice population as its
building block. It is a population or ‘list’ recognised over many years
by patients and professionals alike. For that reason it was chosen as
the population base for the Integrated Care Pilots of the Primary and
Community Care Strategy of the NHS ‘Next Stage Review’ (2008)
and even more fundamentally as the building block of the soon to be
General Practice led Clinical Commissioning Groups.
• However local agreed choice of this and other aspects must prevail.
• Local ownership of new approaches is essential.
The Primary Care ‘Home’
• Population based primary care is where the needs of the
individual and of the community can be met
• Home for all PC providers (Pharmacists, Dentists,
Optometrists), CHS and Social Care
• And potentially many currently working in hospitals
• Delivering on;
• Improved service quality and responsiveness to patients’ individual
requirements
• Long Term Conditions care
• Care closer to the patient’s home
• The ‘home’ for extended skills and services
• Service redesign which promotes clinical innovation and excellence
• A reduction in unnecessary or inappropriate care leading to better
value for money as clinicians prioritise to keep overall health
expenditure within budget
• Where bio-clinical focus and addressing the social determinants of
health can be the responsibility of one provider organisation
• Importance of relationship with local government and third sector
Integration, relationships and new partnerships
• From formal integration as part of a spectrum that enables
integration through such as joint ventures through to virtual
organisations - but fundamentally with a clarity of governance and
accountability. Where patient care depends on various forms of
networking/partnerships, clarity of where accountability and
responsibility lies is paramount.
• And for providers, having a population focus can break the
‘shackles’ of too rigid a split that currently occurs between the
commissioner and provider. Enabling more ‘liberation’ of all
providers to be truly partners of commissioners. Enabled
community based accountable population based providers that can
take over some of the tasks currently undertaken by commissioners.
Only actual contract setting needs to be separated in the
commissioning cycle
• Commissioners may need choices of integrated organisations from
which to choose which does imply at least some overlapping
boundaries of providers