Transcript Title slide - Imperial College London

6th GCC Primary Health Care Conference
Riyadh
Kingdom of Saudi Arabia
05 June 2007
The Effectiveness of
Primary Care
Elizabeth A. Dubois
Associate Director of Public Health / Health Economist
Wandsworth Teaching PCT, London, UK
Content…
• Priorities
for Primary Care
• Effectiveness of Primary Care
• Evaluation
• Conclusion
Priorities for Primary Care
1. Prioritise Expenditure
2. Control Substitution
3. Responsiveness to Population & Accountability
4. Ability to Deliver
5. Roles of PC Team
6. Diversity & Quality
7. Demand Management
8. Education & Training in PC
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Factors Influencing Care
choice
satisfaction/
quality
Patients
clinical
freedom
equity
Physicians
Government
standards
costs
Prioritise Expenditure
• Agree responsibility for prioritising:
– Services
– Service spend
• Budget holding – powerful tool of change
• Professionals responsible for resource allocation
• Micro-level service development
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Facts…..
Cost-Effectiveness (Intervention cost/case):
• Telephone Call
• Primary Care
£15
• GP with Special Interest
£55
• Outpatient
£150
• Day Surgery
£500
• Inpatient (2ndary Care)
6
£16
£5000
Facts…..
Cost-Effectiveness (Intervention cost/case):
• Telephone Call
• Primary Care
£15
• GP with Special Interest
£55
• Outpatient
£150
• Day Surgery
£500
• Inpatient (2ndary Care)
7
£16
£5000
Control Substitution
• Shift work from secondary care to primary care
• Define primary and community care in its own right, not
a residual
• Vehicle of change rather than the receiver of it
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Responsiveness to Population &
Accountability
• Define core population need
– Health needs assessments
– Comparative audits
• Accountability to patients
• Accountability to the managers
• Accountability to the profession
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Ability to Deliver
• Commitment of resources
• Development of leaders
• Teambuilding
• Training in resource management
• Training in public health tasks
• No hierarchy → matrix organisation
• Right people, right skills, right time
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Roles of PC Team
• Re-examination of the role of the GP
• GPs cannot control and do all key tasks
• Re-examine the professional & clinical roles of:
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Manager
Nurse
Pharmacist
Psychologists
• Link public service values + private sector initiatives
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Diversity & Quality
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Grow your own vision
Build upon skills and motivation
Develop new roles
Encourage innovative partnerships (voluntary sector, private
sector, community, academic departments)
• Addressing poor quality; monitor through:
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Organisational development
Investment
Audit
Performance monitoring
Professional assessment
Retraining
Managing Demand
• One, if not the, most critical elements
• In the absence of DM, service development is irresponsible
• Increased demand due to:
– Consumer expectations
– Patient mobility
– Increasing complex problems
– Ageing population
– Advances in drugs & technology
• Address capacity issues innovatively & responsively
• Prevents service inadequacies
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Suggestions for Demand Management
• Patient education initiatives
• Non-doctors doing medical role
• Training GPs in risk management
• Training in teamwork development
• Audit of referrals / consultations w/ peers
• Timely patient information (minorities, new patients)
• Use volunteers and/or carers
• Control through monitoring & policy
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Education & Training in PC
What are we doing now? What do we want to be
doing…and how shall we get there?
• Skilling
• Teambuilding
• Monitoring
• Training & development
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Change Organisational Behaviours
Choice
Quality
Integration
Costs
Change Physicians’ Behaviours
Evaluation of Effectiveness in Primary Care
• Explicit responsibility for decision making
– Baseline measures specific to time and place
– Consider objectives of stakeholders
• Better partnerships with other organisations
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Community
Social services
Psychiatry
Geriatrics
Voluntary
Private
Evaluation of Effectiveness in Primary Care
• Value for money
– *Key issue
– Compare transaction costs
– Measure need & patient outcome (but v. difficult)
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Responses to population need
Accountability to management & patient
Efficient provision of appropriate care
Evidence-based interventions
Management of demand
Equity of health care delivery
Sustainability and stability of systems
Staff retention & recruitment
Conclusion
• Colossal agenda but real opportunity
• Focus on ‘appropriateness’ to estb. good practice
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Effectiveness of interventions
Efficiency
Patient acceptability
Clinical experience
Right people, right skills, right time
Public Health skills crucial
Managerial experience crucial
User input crucial
Clear responsibilities, particularly budgetary
Clear objectives
Robust evaluation
Sense of mutual respect for all professions working in primary and community care
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References
• Carruthers I. (1994) Total fundholding in the mainstream of the
NHS. Primary Care Management. 4: 7-9.
• Fry J, Light D and Rodnick J. (1995) Reviving Primary Care: a
US – UK comparison. 118-40. Radcliffe Medical Press, Oxford.
• Littlejohns P, Victor C. (1996) Making Sense of a Primary Careled Health Service.14-28. Radcliffe Medical Press, Oxford.
• Starfield B. (1992) Primary Care: concept, evaluation and policy.
Oxford University Press, New York.
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Shukran Jazeelan
Elizabeth A. Dubois
Wandsworth Teaching PCT, London
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