Re-organisation of Primary Care

1. Re-organisation of Primary Care Lyndon Miles Chairman Gwynedd LHB GP Bron Derw Medical Centre

2. Outline • Context, the wider NHS • Improving Health in Wales • Commissioning • Primary care • Optometry • Dentistry • Pharmacy • General Practice • Developing services locally

3. Context - “Traditional NHS activities” • Comprehensive “care delivery” • Mortality falling, patients healthier • New drugs and treatments • Technological improvements • Funding increasing • All’s well? • increasing demand • NHS failing to cope – WHY? • What’s happening to Health (rather than illness)

4. Inequalities in health – expectations of life

5. Inequalities in health – unequal expectations of life

6. Inequalities in health – SMR’s

7. Inequalities in health – mortality rates by economic activity

8. Inequalities in health – Direct age standardised rate ratios by housing and car ownership

9. Source: Whitehead M & Dahlgren G Inequalities in Health 1996

11. Partnership with Local Authorities

12. NHS problems • Demography • Demand / waiting times / capacity to cope • Increasing specialisation • Rising standards • Morale / HR issues • Financial issues • Chronic disease management !!!

13. System performance Secondary care

14. Rising standards (investigations and treatments) Secondary care

15. Rising standards (investigations and treatments) Rising demand, falling prevention Secondary care

16. Rising standards (investigations and treatments) Rising demand, falling prevention Secondary care Dysfunctional system

17. How do we compare with other countries?

18. UK Relative to 18 European countries Best Worse

19. Health Personnel – comparison with Europe 1995 (per 1000 population)

20. Country - spend on health care (% GDP)

21. SWEDEN (UK) Relative to 18 European countries Worse Best

22. Ranking of Health System Performance 2000 (WHO)

23. NHS national solutions • Focus on health • Job evaluation • New contracts • Re-organisation to improve efficiency

24. Better Health, Better Wales • Life expectancy in Wales 3-4 years less • Life expectancy (valleys) 5 years less • Infant mortality, heart disease, cancers, LT illness all worse

25. Improving Health in Wales • Reorganisation of structures • New accountability arrangements • Focus on partnership working • Needs led / clearer mechanisms • County HSC&WB Strategies

26. LHB Functions • Corporate and Clinical Governance • Securing and Providing Primary & Community Health Care Services • Securing Secondary Care Services • Improving the health of communities • Partnership • Public Engagement • Provision of services

27. Healthcare Commissioning Needs assessment Address problems Service delivery analysis Review performance Consider professional and commissioning plan / WAG guidance and views of clinicians & patients & stakeholders, Executive engagement Develop service commissioning with providers plans (including resource implications, public consultation if necessary)

28. Care pathway analysis • Consider patient’s journey through system • Allows holistic analysis, not organisational needs • Identifies blocks, delays, inefficiencies, duplications etc • Should improve patient experience and improve NHS efficiency

29. Primary Care • Optometry • Dentistry • Pharmacy • General Practice • Diagnostics • Estates • IT

30. Optometry - “The Future of Optometry Services in Primary Care in Wales” • Developed role • detection pathology / referral / monitoring • therapeutic treatment • Over 75 assessment / driving • Children • Specialist contact lens work • Occupational / sport eye care • Schemes • Cataracts; glaucoma; low vision; minor problems etc • Professional development • IM&T, Premises, workforce planning

31. Dentistry – “Routes to Reform” • Mixed economy • Currently: Dental health worse than England; decline in children disappointing; marked inequalities; adults retaining teeth longer • Challenges: High restorative need; new approaches to children; action re inequalities; fluoridation • New Dental Contract • LHB commissioning / local dental action plans • 17% increase in training places in Wales • Dental grant schemes

32. Pharmacy – “Remedies for Success” • Need for integrated strategy • Vision = co-ordinated service helping people to: • Maintain health • Manage common ailments • Best use of prescribed medicines • Manage long term medication needs • Re-designing services • Making best use of resources

33. Information Technology“Informing Healthcare” • Single electronic record • Confidentiality project • Workforce empowerment • Patient and carer empowerment • Service improvement • Knowledge and information management

34. General Practice • “The Future of Primary Care” • All primary and community based • Patient and public involvement (joint LHB / LA action) • CHC have statutory inspection rights over primary care (NHS Wales Bill – as from 1/4/04) • Address disadvantaged groups (through SAFF process) • Recognise work towards health (HLC’s, H. Alliances) • nGMS contract

35. nGMS contract • http://www.visualproductions.co.uk/new%20contract/hh_start.htm • Practice based contract • Out-of-hours opt-out • LHB commissioning • Clinical governance / Chronic Disease management / organisational monitoring • IT • New GP Career structure

36. Changes to GP • Chronic disease clinics • Local additional / enhanced services • e communications • Prescribing, dispensing, x interfaces, paperless, single records • Resource centres • Links with SS / care assessors / unified assessments • Pathway developments • Referrals analysis

37. What’s happening in Gwynedd? • OOH • Additional / enhanced • Care pathways • Extending roles within practices • Promotion of primary care teams • Estate strategy ?? Resource centre

38. Task? • Advise on how a clinical service might be re-designed? • Agree which service (pick one that involves crossing boundaries) • Consider patient’s pathway • Any blocks / delays / skill-mix • Resource neutral (or limited)