WHO Collaborating Centre Imperial College London Ref 212/2011 Primary Care The UK Experience...

WHO Collaborating CentreImperial College LondonRef 212/2011

Primary CareThe UK Experience

Professor Salman Rawaf MD PhD FRCP FFPH

Chile Primary Care Conference, Santiago 6-7 Dec 2011

s.rawaf@imperial.ac.uk

Content:1.Four Questions2.The evidence 2. Primary Care led NHS in the UK3. Current & Future Trends in Primary

Care4. Chile: the context

© WHO C Centre, Imperial College London

© WHO C Centre, IC London

Four questions to address:

How to improve users satisfactions with the services?

How to ‘develop’ skilled personnel & guarantee its permanence at PHC?

How to guarantee access to medicine; provide problem-solving therapeutic

and Dx technology?

Ch Diseases: which community development strategies that PHC should integrate?

1

2

3

4

WHO C Centre, IC London

The Evidence

© WHO C Centre, IC London

Why PHC?

Modern Society expect that:

- Health is a human right

- Access to quality & comprehensive services near home

- Personal & Continuity of Care My Doctor - Financial Protection (free at time of Delivery)- Competent Health Professionals

WHO World Health Report 2008

WHO C Centre, IC London

© WHO C Centre, IC London

High Performi

ng Systems

Less Well Performi

ng Systems

vs

Principles: Coverage, Equity, less defined Financial Protection

Structure:Structure: Primary Care-led Primary Care-led Hospital-ledHospital-led

Focus: People-centred/ Physician-centred/ Population Health Disease orientated

Sustainability:Sustainability: High LowHigh Low

HRH: Competency-based No. Based

40%Healthy

40%Healthy

With Risk Factor(s)

10% Acute Illness

10% Disability

Rawaf’s Model for Burden of Disease - 2001

In Any Given Population

© WHO C Centre, IC London

Weak PHC Countries

Strong PHC Countries

1970 1980 1990 2000

500

0

1000

OECD Countries: Potential Years Life Lost (PYLL)

© WHO C Centre, Imperial College London Source: B Starfield

Universal Coverage Total Population A Whole System Approach Equity Social Protection Solidarity (Social Contract) Choice Engagement

• Telephone Call (NHS Direct) £16

• Family Physician £15

• Walk-in-Centre £55

• GP with Special Interest £75

• Hospital Outpatient £150

• Day Care £500

• One-Day Admission £1,000

• Inpatient (2ndary Care) £5,000

• High Specialist Care £20,000

PHC

Hosp C

Cost-Effectiveness (Intervention cost/case):

© WHO C Centre, IC London Source: Wandsworth PCT 2006

WHO C Centre, IC London

Universal Coverage through PHC

© WHO C Centre, Imperial College London

Professor S Rawaf

The System Its Foundation Structure Operation & Management Financing Performance Challenges The Future

© WHO C Centre, Imperial College London

Professor S Rawaf

Nye Bevan (1897-1960)

The Architect of the British NHS 1946 (July 1948)

© WHO C Centre, Imperial College London

Professor S Rawaf

A National Health Service…

“…to secure equal access to comprehensive healthcare for every individual across the country regardless of their ability to pay”

N Bevan, 1946

Strong Founding Principles:

1. Funded through Taxation2. Free at the point of Delivery3. Comprehensive4. Equitable5. Public Involvement

© WHO Collaborating Centre, London

Professor S Rawaf

Strong Health System(1948-Present)

Primary Care Hospital Care

Public Health

© WHO C Collaborating Centre, London

Professor S Rawaf

© WHO Centre, Imperial College London

H

P C

PublicHealth

Fully integratedHealth System

© WHO C Centre, IC London Source: RCGP 2010, WONCA 2010

The UK General practice

Population Registration GP (Family Physician)-Based (0.6/1000 p) A single portal entry to the HS; Available 24 hours a day; The first and vital contact A gate-keeping function (selective referrals); Long term & the continuity of personal and family care; Health, Clinical morbidity, Social problems, local needs, small population Stakeholder to local public health

GP

HOSPITAL

1 2 3 NHS Direct

100%Registration

10% 10%

© WHO C Centre, Imperial College London

Professor S Rawaf

A & E

GP

HOSPITAL

1 2 3

Cost: 10% + 11% 50% Acute, 20% MHContacts: 80% - 90% 10-20%

NHS Direct

100%Registration

10% 10%

HV

PN

DN

CPN

Patients Group

Home Visits

Source: S Rawaf 2007

Midwives

© WHO Centre, Imperial College London

GP

HOSPITAL

1 2 3 NHS Direct

100%Registration

10% 10%

© WHO C Centre, Imperial College London

Professor S Rawaf

A & E

Power

Resp

onsibili

ty

Contro

l

FP

HOSPITAL

1 2 3

Cost: 10% + 11% 45% Acute, 20% MH +Contacts: 85% - 90% 10-15%

Health Line

© WHO Collaborating Centre, London

Professor S Rawaf

© WHO C Centre, Imperial College London Source: Commonwealth Fund, 2007

Australia Canada Germany NZ UK

Overall Ranking 2007 3.5 5 2 3.5 1Quality Care 4 6 2.5 2.5 1

Right Care 5 6 2.5 2.5 2

Safe Care 4 6 3 4 2

Coordinated care 3 6 4 2 1

Pt Centered Care 3 6 2 1 4

Access 3 5 1 2 4

Efficiency 4 5 3 2 1

Equity 2 5 4 3 1

LH Productive Life 1 3 2 4.5 4.5

Health Expenditure

Per Capita, 2004 $

2,876 3,165 3,005 2,083 2,546

High Performing systems

© WHO Centre, Imperial College London

Professor S Rawaf

Challenges to UK Health System

20% 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% 2% 4% 6% 8% 10% 12% 14% 16% 18% 20%

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-8990+

-20 -18 -16 -14 -12 -10 -8 -6 -4 -2 0 2 4 6 8 10 12 14 16 18 20

Men Women

20% 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% 2% 4% 6% 8% 10% 12% 14% 16% 18% 20%

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-8990+

-20 -18 -16 -14 -12 -10 -8 -6 -4 -2 0 2 4 6 8 10 12 14 16 18 20

Men Women

Wandsworth London

Source: ONS Mid 2002 Population Estimates

DPH Independent Report 2004

Professor S Rawaf

1. Huge Variations in Population’s needs Accurate Health Needs Assessment

© WHO Centre, Imperial College London Source: ippr 2008

2. Ageing PopulationHealth + Social Care (Joint Needs Assessment, Joint Commissioning)

Professor S Rawaf

Proportion of a single-person households, UK 1971-2021

© WHO Centre, Imperial College London Source:McCrone eat al 2008 ippr 2008

Projected Number of People with Depression, UK 2007-2026 Professor S

Rawaf

85+

75-84

3. Changing Burden of DiseasesFlexible Service Delivery

© WHO Centre, IC London

Efficiency – GP Commissioning Groups

Public Health & Primary Care

Addressing Health & Risks - Advanced QOF

How to shift Power? HC to PC Incentives

OH & PC: full integration, partial, embed, collaborative..

© WHO Centre, Imperial College London

Professor S Rawaf

Medical Education & Training

MBChBMBBS

They Need: Structured Training

© WHO Centre, Imperial College London

Professor S Rawaf

12345

F1F2

123

2345

1

A-level University

University(Medical School)

FoundationSchool (Virtual)

Med/Surg/PH/Diag General Practice

PMET Board +R. Colleges(Standards)

GMC

CST Principle GP Consultant

© WHO Centre, Imperial College London

Professor S Rawaf

Developing Family Medicine

EquitableCommunity-basedInfrastructure

EquitableCommunity-basedInfrastructure

Strong Postgraduate Training

Strong Postgraduate Training

Solid UndergraduateLearning

Solid UndergraduateLearning

© WHO Centre, Imperial College London

Professor S Rawaf

1

2

New Entrance:Introduce A structured Training ProgramFamily Medicine 3-5 Years .. Iranian BoardCurrent PHC DoctorsOne Year on-the-Job Training Program Postgraduate Diploma in Family Medicine

WHO C Centre, IC London

Some key Observations

It is the most important factor to convince people

about the value of FM

Training Competencies Attitude PCM Personal-relationship Public involvement

1. Quality in Family Medicine

© WHO Collaborating Centre, London

Professor S Rawaf

0

20

40

60

80

100

120

140

160

180

1993/4/5 1995/6/7 1997/8/9 1999/2000/1 2001/2/3 2003/4/5 2005/6/7 2007/8/9

England: Deaths due to Vascular Diseases

Page 39

Change in antibiotic prescribing 1995-1998: GPRD

Age Males (%) Females (%)0-4 -22 -235-15 -26 -2316-24 -15 -1625-34 -18 -1535-44 -16 -1545-54 -13 -1255-64 -9 -1065-74 -9 -675-84 -9 085+ -10 -1

Page 40

% P

atie

n ts

Re f

erre

d /Y

ear

UK

US Health Plans

Page 41

National Prevalence (England)

Page 42

Percentage of patients with diabetes with HbA1C <=7.4% in

last 15 months

Page 43

GMS quality indicators (process) - median practice achievement

0

10

20

30

4050

60

70

80

90

100

BMI

Smok

ing st

atus

Smok

ing a

dvice

Hb1Ac

Blood

pres

sure

Retina

l scr

eenin

g

Pulses

Choles

tero

l

2003

2005

Page 44

GMS quality indicators (outcome) - median practice achievement

0

10

20

30

40

50

60

70

80

90

100

HbA1c < 7.4 HbA1c < 10 Cholesterol < 5 BP < 145/85

2003

2005

WHO C Centre, IC London

2. Incentives

Incentive vs No incentivein Family Medicine

WHO Centre, IC London

Campbell et al. Effects of Pay for Performance on the Quality of Primary Care in England, NEJM 2009

QOF

WHO C Centre, IC London

Addressing the 4 Questions:

© WHO C Centre, IC London

Four questions to address:

How to improve users satisfactions with the services?1

Quality, Person-Centre Med, Continuity

© WHO C Centre, IC London

Four questions to address:

How to improve users satisfactions with the services?

How to ‘develop’ skilled personnel & guarantee its permanence at PHC?

1

2

Incentives Based Training on FM (Quality), Competent Workforce (CPD, Revalidation etc)

© WHO C Centre, IC London

Four questions to address:

How to improve users satisfactions with the services?

How to ‘develop’ skilled personnel & guarantee its permanence at PHC?

How to guarantee access to medicine; provide problem-solving therapeutic

and Dx technology?

1

2

3

Strategic & Op Management, Health Model, Integrate with public health and hospitals

© WHO C Centre, IC London

Four questions to address:

How to improve users satisfactions with the services?

How to ‘develop’ skilled personnel & guarantee its permanence at PHC?

How to guarantee access to medicine; provide problem-solving therapeutic

and Dx technology?

Ch Diseases: which community development strategies that PHC should integrate?

1

2

3

4

Understanding H Needs (HNA), Integrate PH and PHC

WHO C Centre, IC London

........ and Finally

© WHO Collaborating Centre, London Source: BMJ, 2008

© WHO Collaborating Centre, London Source: BMJ, 2008

Thank you