THE An overview

Dr. Josep M. VilasecaUASP, 27 d’octubre de 2009

Founding principlesTony Delamothe, deputy editor.

BMJ  2008;336:1216-1218 (31 May)

Britain’s National Health Service (NHS) came into existence on 5 July 1948. It was the first health system in any Western society to offer free medical care to the entire population. It was, furthermore, the first comprehensive system to be based not on the insurance principle, with entitlement following contributions, but on the national provision of services available to everyone.

NHS OrganisationNHS Aims:• To provide medical care free at point of use• To rich and poor alike• in accordance with medical need

2 beliefs:• Those who need care will come forward• Those who provide care know what is

required and how to provide it

ELS QUATRE (O MÉS?) NHS

• NHS England• NHS Northern Ireland• NHS Wales• NHS Scotland

NHS Organisation

Constant change5 phases:1948 - 74: Administrative1974 - 82: Planning1982 - 90: Managed1990 - 97: Market1997 - : The New NHS!!

NHS OrganisationThe New NHS

H ea lthIm p rovem en tP rog ram m e

L oca lA u th orit ies

P rim ary C are G rou p s

H ea lth A u th orit ies N H S Tru s ts

D oHN H S E

R eg ion a l O ffices

S ec re ta ry o f S ta teTyp e tit le h e re

ASPECTES DIFERENCIALS• Els contractes (p.e. directe NHS – single-handed

GP) • La competència • Els tipus d’empreses proveïdores de serveis

sanitaris: persones físiques, beneficència, entitats sense ànim de lucre, empreses privades

• El càlcul de costos• Els sistemes d’informació• Els indicadors en temps real• L’assegurança, les cobertures

What are Primary Care Trusts (PCTs)?

Healthcare in the UK is divided into 'primary' and 'secondary' services.

Primary care services are provided by the people you normally see first when you have a health problem. It might be a visit to your doctor or dentist, to your optician for an eye test, or a trip to your pharmacist. NHS walk-in centres and the NHS Direct phone service are also part of primary care.

All of these primary care services are managed by Primary Care Trusts (PCTs). There are about 152 Primary Care Trusts in England, each one covering a separate local area.

What are Primary Care Trusts (PCTs)?PCTs are a very important part of the NHS, and they get about

80% of the total NHS budget. PCTs decide what health services a local community needs, and they are responsible for providing them. They must ensure that there are enough services for people within their local area, and that the services are accessible. These services include:

GPs, Dentists, Pharmacists, Opticians, NHS Direct, and NHS walk-in centres.

PCTs make decisions about the type of services that hospitals provide and are responsible for making sure that the quality of service is high enough. They also control funding for hospitals.

As PCTs are local organisations, they are in a good position to understand the needs of their local community. They make sure that NHS organisations work effectively with local authorities, and other agencies that provide local health and social care services, so that the local community's treatment needs are met.

NHS walk-in centres (WiCs), which first opened in 2000, offer convenient access to a range of NHS services. Today WiCs are managed by primary care trusts (PCTs).There are around 93 NHS WiCs available in England, dealing with minor illnesses and injuries. This includes:

• infection and rashes, • fractures and lacerations, • emergency contraception and advice, • stomach upsets, • cuts and bruises, or • burns and strains. NHS WiCs are predominantly nurse-led first-contact

services available to everyone without making an appointment or requiring patients to register. Most centres are open 365 days a year and are situated in convenient locations that give patients access to services even beyond regular office hours.

WHAT SERVICES DO GPs OFFER?• Essential Services – All Practices• Additional Services – Vast Majority of

Practices– Cervical Screening (Smear Tests) – Contraceptive Services – Vaccinations and Immunisations – Child Health Surveillance – Maternity Medical Services– Minor Surgery

• Enhanced Services – Selected Practices

ENHANCED SERVICES INCLUDE:

• Childhood immunisations.• Influenza immunisations.• Services for violent patients.• More complex minor surgery.• Services for alcohol and drug misusers.• Anti-coagulation monitoring.• Intra-uterine Contraceptive Device (IUCD) fittings.• Specialised care of patients with depression.• Immediate care and first response care.• Care of the homeless.• Intrapartum care.• Minor Injury services.• Specialised sexual health services.• Specialised Multiple Sclerosis services.

Practice based commissioning: clinicians in commissioning

Practice based commissioning (PBC) is about involving GP practices and other health and primary care professionals in the commissioning of services.

Commissioning (extract from a letter of David Colin-Thomé, National Director for

Primary Care

By engaging in the commissioning process through PBC, GPs have the opportunity to shape the types of care available for patients, determine how resources are invested to best effect and buy the services their patients need. We have a unique and deep knowledge of our registered patients needs and what happens to them when they are referred on. We know that with more influence over the whole clinical process how much better we can make the NHS and in the process release resources to be used in community settings.

OUR VISION FOR CLINICAL COMMISSIONING(extracte del document World Class Commissioning de

l’NHS, març 2009)

PBC recognises the central role of primary care clinicians – through the hundreds of thousands of treatment and referral decisions they make each day – in using NHS resources to deliver high-quality care for all. PBC gives local clinicians much greater power and influence, working in partnership with PCTs, to shape how these resources are invested so that they deliver better health, better care and better value for local practice populations and for taxpayers. Especially in financially challenged times, clinical empowerment is not a nicety but a necessity.

BBC news Thursday 31 July 2008 (online)A terminally ill woman who has been fighting to get a kidney cancer drug has been told her

local health trust has refused to pay for it once again.

Jean Murphy, 63, from Salford, went to court after Salford Primary Care Trust refused to pay for the drug Sutent.

The High Court told the trust to reconsider its decision, but it has now refused for a third time.

Chief executive of Salford PCT, Dr Mike Burrows, said the decision had been made after "significant consideration".

He said in a statement: "A process review panel took place at the request of Mrs Murphy and her legal advisers.

"After significant consideration the review panel upheld the decision of the commissioning panel not to fund the drug Sutent for Mrs Murphy."

Jean Murphy has already taken her case to the High Court.

He added: "We realise this has been a very difficult time for Mrs Murphy. However the PCT now believes it has examined in depth all aspects of this case and the conclusion of all steps of this process support the original decision."

Mrs Murphy's husband Michael, who has Crohn's disease, a heart condition and diabetes, has now said he will stop taking his own life-saving medication.

His wife is his sole carer, and they believe the drug Sutent could prolong her life.

The drug is available on the NHS to patients in Cheshire and Merseyside, but not Greater Manchester as it has not been approved by the National Institute of Clinical Excellence (NICE).

People in Greater Manchester can only receive it through clinical trials - and Mrs Murphy does not fit the criteria.

When she was first told the trust would not pay for the drug, Mrs Murphy said: "There's no other thing for me to have and I'm frightened of dying - really frightened of dying."

She has undergone several unsuccessful treatments to slow the cancer's progress and her consultant said she would be an ideal candidate for Sutent.

Mr Murphy said he now has "no option" but to refuse his own treatment.

"I love and care for my wife, and I'll do anything for her," he said.

"I've helped her through the years, and we've been married 25 years, and for them not to help, well I don't want any help from them."

The couple's daughter, Cathy Ostasz, said the PCT were sending her mother to an early grave.

"This family will fall apart without my mum," she said. "This is all because of Salford PCT and I think they're

disgraceful. They are sending my mother to a premature death."

Cancer patient wins drug battleAmanda Crook

October 22, 2008 - Manchester Evening News (online)

A TERMINALLY ill grandmother has won a landmark battle to force health chiefs to pay for a life extending cancer drug - by proving it works.

An anonymous donor stepped in giving Jean Murphy, 62, £10,000 to pay for pioneering drug Sutent to tackle her kidney cancer after Salford primary care trust refused to fund it four times.

Mrs Murphy says she felt better within days of taking the drug and now scans have confirmed she has responded 'exceptionally' well to the treatment - prompting PCT bosses to change their minds.

Mrs Murphy was told she had 18 months to live in April but since starting treatment says she has stopped using a wheelchair, oxygen supply and stair-lift. Before taking the drug she was virtually housebound but now she is shopping for the family and socialising again.

She hopes her six month battle, which took her to the High Court, will pave the way for other patients to be offered a two-month 'taster' of the drug on the NHS to see if it works for them. She said: "I am overwhelmed, I cannot believe it, even though I have had it in writing I have to keep looking at it again and again because we have had such a long fight and they refused me for so long.

"I really hope that what I have been through will change things for other people, so that no one else has to go through what my family has done. I think everyone who doctors think would benefit from Sutent should get to try it for two months - anyone can accept not having a drug that doesn't work for them.

"I knew straight away that the drug was working, I am a different person now, but it was great to have my doctor confirm it, saying my tumours have shrunk dramatically. "We want to thank everyone at the hospital, my solicitor and all the people who have contacted us, supporting us and most of all

the donor who has made this possible."

Benefit

On average Sutent patients can expect to live an extra six months. The government's health watchdog issued draft guidelines a few months ago saying Sutent is effective but too expensive to be provided on the NHS. Mrs Murphy and doctors at The Christie hospital in Withington have written asking them to reconsider before publishing their final decision.

Salford PCT chief executive Dr Mike Burrows said the PCT had agreed to fund Mrs Murphy's treatment because she was one of a 'minority' for whom it was effective. He said: "We hope the treatment continues to be effective for Mrs

Murphy in line with the initial indications.

"NICE guidance states that patients currently receiving Sutent should have the option to continue therapy until the patient and their clinician consider it appropriate to stop.

"The funding of new high cost drugs, particularly for cancer treatments, will continue to be an emotive and challenging issue for PCTs to manage, given our responsibility as the local leader for health, and the need to work within the financial resources available to us.

"The PCT has to act in a way that ensures we have high quality, convenient and timely health services and

treatments available to everyone in Salford."

Funding

Prof Robert Hawkins, Mrs Murphy's consultant at the Christie said: "I am delighted Jean is doing so well and has responded so positively to Sutent. I'm also delighted that she be able to have her treatment funded on the NHS as this will take away a lot of anxiety for her and her family. We are so grateful to the anonymous donor who has made this all possible."

He says around half of patients respond well to Sutent but around 10 per cent - including Mrs Murphy - have an

exceptional response to it.

Last summer broadcaster Tony Wilson, who later died of a heart attack, had to rely on showbiz friends to pay for the drug because health bosses wouldn't approve the treatment.

Mrs Murphy's solicitor Mark McGhee said: "Obviously Jean is grateful that the PCT has finally done the right thing. We now hope this sets a precedent for all kidney cancer patient sufferers in Salford."

DEBAT

Moltes gràcies!Josep M. Vilaseca