Embed Size (px)
Citation preview
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
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
