The Primary Care Home

The Primary Care Home Professor David Colin-Thomé Independent Healthcare Consultant david@dctconsultingltd.co.uk www.dctconsultingltd.co.uk

The Primary Care Home • All providers need to also define a population responsibility if they are to be a more influential and proactive organisation. This is of particular import to improve the care of people who have a long term condition. • Future care will inevitably be more integrated and overtly accountable, much more based in community settings and optimally delivered if chiefly responsible for a defined population. • Hence the concept of the Primary Care Home, a community based, integrated, accountable home for population care where the needs of the individual and of the community can be met. Served by an holistic budget that enables a ‘make or buy’ approach to care delivery and commissioned by the statutory commissioner(s)

Building on the past

Primary Care • ‘soul of a proper, community orientated, health-preserving care system’. Berwick DM. A transatlantic review of the NHS at 60. BMJ 2008;337:a838 • “The well known but underappreciated secret of the value of primary care is its person and population, rather than disease, focus” (Starfield, 2009,). • “There is lots of evidence that a good relationship with a freely chosen primary-care doctor, preferably over several years, is associated with better care, more appropriate care, better health, and much lower health costs.” Starfield • The ability to “organise the chaos of the first presentation’. Paul Freeling late emeritus Professor of General Practice

Primary Care “That aspect of a health services that assures person focussedcare over timeto a defined population, accessibility to facilitate receipt of care when it is first needed, comprehensiveness of care in the sense that only rare or unusual manifestations of Ill health are referred elsewhere, and coordination of care such that all facets of care (wherever received) are integrated.” Starfield, B. J Epidemiology and Community Health 2001; 55:452-4 • Benefits; • Higher patient satisfaction with health services • Lower overall HS expenditure • Better population health indicators • Fewer drugs prescribed per head of population • The higher the number of family physicians the lower the hospitalisation rate.

General PracticeWilson T, Roland M, Ham C. The contribution of general practice and the general practitioner to NHS patients, J R Soc Med 2006; 99:24–28 We identify three areas in which British general practice performs well, leading both international policy analysts and the public to their favourable conclusions: Equity Quality Efficiency And three important characteristics that contribute to this success: Co-ordination Continuity Comprehensiveness

Primary and community care strategy: overview Highly valued services Ties to local communities A decade of improvements Strengths Case for change Challenges Services that don’t join up Unwarranted variability in quality Changing demands Responsive and integrated care Choice in primary & community care Empowered patients & public Services shaped around individuals Our vision Promoting health throughout life Access to healthy living services Tackling health inequalities Promoting healthy lives Transforming community services Driving continuous improvement Assuring essential standards Continuously improving quality Leading local change Reinvigorating PBC Piloting integrated services World class commissioning Health and social care

It is the unique attributes of the GP system that has lent itself well to being the central plank of post 1990 English NHS reform. • GP Fundholding where budgets could be allocated to a GP practice population and not tied to a specific disease or care group. This allowed an opportunity for a more imaginative use of the monies to provide better care for their patients.( Julian Le Grand, Nicholas Mays, and Jo Mulligan (1998) (eds) Learning from the Internal Market: a Review of the Evidence. London, Kings Fund). • The Quality and Outcomes Framework which is the largest pay for performance system for clinicians world-wide and can only be successfully delivered to a defined population. • And in 2013 the General Practice led Clinical Commissioning Groups that will replace the current Primary Care Trust managerially led commissioners. The Groups will receive their monies based on aggregated practice list based allocations and every GP practice will have to be a member .

NHS Reforms EnglandShapiro, Colin-Thomé, Mulla. BMJ May 2011 • Although the current English NHS reforms have been developing over two decades, their direction has been remarkably consistent. • Three basic elements have emerged: the separation of provision from procurement (to try to reduce the acute sector’s supply side pressures on demand); the introduction of some contestability to further reduce complacency among providers; and the devolution of decision making more closely to the patient interface to increase clinicians’ personal involvement in these decisions. • Naturally, the mechanisms have changed and evolved but the underlying principles have weathered changes in government, health secretaries, and financial circumstances. Indeed similar principles have underpinned health service reform internationally.

Improving on the present

Improving the quality of care in general practiceReport of an independent inquiry commissioned by The King’s Fund 2011 • ‘What my colleagues and I are anxious to say here is that the study of quality in general practice is an underdeveloped area. Many reasons might be offered. One which comes through clearly is that, for many in general practice, it is not an area of health care greatly given to self-reflection and self-challenge’ • Quality extends to the way in which all types of teams work for the benefit of patients and the wider public. • Surveys show that public satisfaction with the NHS is higher than it has ever been and that general practitioners and other primary care staff enjoy high levels of trust and confidence from patients.

Improving the quality of care in general practice. Report of an independent inquiry commissioned by The King’s Fund 2011 • There was relatively little information on the quality of general practice and no comprehensive overview • The evidence brought together in this report shows that while standards of general practice are generally high, there are no grounds for complacency. On many of the available indicators, there are variations in performance, suggesting that more needs to be done to realise Nye Bevan’s vision that the NHS should ‘universalise the best’. • The panel quite rightly emphasises the role that practices themselves have in tackling variations in the quality of general practice and in creating an environment for quality improvement • It is not clear whether action by general practice will be sufficient. Like other professions, general practice includes conservatives as well as innovators..

The Medical Home • In the USA over many years has seen a focus by some health care leaders to fashion a system for co-ordination of care out of their country’s non- system approach to health care delivery. The concept of the ‘Medical Home’ is such an approach discussed for some thirty years. • Of course some notable USA ‘meso’-organisations have developed outstanding system approaches; Kaiser Permanente, the Veterans Health Administration and so on. • .

USA Healthcare Reform • President Obama with his reform programme is attempting in an often hostile environment to bring some national system approaches to bear on the wider health care service via organisational models. His National Protection and Affordable Health Act includes the concept of Accountable Care Organisations • So what of the UK? Where is our ‘Medical Home’? And our ‘Accountable Care Organisation’? To me even if not universally acclaimed as such, it already exists - it is list based general practice where primary care workers combine one to one personal care with the potential of population care. The success of general practice in the UK is based on continuity of care serving a practice population. Good general practitioners have the on-going trusting relationship with and a responsibility for their patients even when those self-same patients are not ‘in front of them’

Creating a sustainable local future

Key elements of Liberating the NHS • Create a patient-centred NHS • Focus on improving their experience and their health outcomes • Empower professionals – end top-down control • Or put another way • No decisions about me without me - an information revolution arming patients and clinicians with more transparent data, helping patients to make more informed choices and hold the NHS to account. • Outcomes that are amongst the best in the world – a shift to a future focussed on better outcomes and away from structures and process. • Empowering clinicians to deliver results – setting them free to make decisions for their patients, for example GPs commissioning services for their local communities.

A New NHS Commissioning • Being the ‘people’s organisation’, • new relationships with the wider health eco system, • the healthcare system leader ensuring quality- safety, effectiveness and patient experience and equally to promote and deliver on innovation, prevention and productivity delivered by providers. • So a key fourth domain is a new and essentially a completely new relationship with providers of care

NHS Healthcare Commissioning is all about good provision • From a strictly NHS focus, commissioners must be about ensuring good provision of care. Key ‘design principles’ essential to improve health and healthcare are • - integrate care, in its widest sense, including social services and the voluntary sector. • - level up general practices to reduce 'unwarranted' variation • - redesign pathways so that care is delivered 'closer to home', reducing the system's current dependence on hospital in and out-patients. • - put in place targeted prevention programmes that addresses the needs of the population

NHS Healthcare Commissioning is all about good provision. • Commissioner is the system leader-as the funder and as the ‘organisation of the people’ • Clinical Commissioning Groups align the incentives • Care can only be improved if the ‘flow’ of care is optimal; - more care in community settings, - better integrated referral - hospital as a flow system - integrated discharge- most after care only in community settings • Where is the provider leadership for the ‘system’ or do they prefer to be a parallel universe? • The providers should undertake much of the work currently undertaken by commissioners • Primary Care provision needs to expand its scope and responsibility. • Hospital or other providers as a principal provider

Long Term Conditions • Nowhere is the coming together of individual and population needs more important than for serving those patients and individuals with long term conditions. • And nowhere is there a more urgent need for organisational leadership. There are many imperatives if we are to deliver a quality, equitable and cost effective service. This applies to all services but the care of those with long term conditions in particular those who have co-morbidity of conditions and especially those who also are frail and elderly should serve as a template, an exemplar and an accountability of NHS. • For most patients, all of their care can be provided in the community • Delivery will depend on the NHS providing optimal care but many facets of the strategy are also for the wider public health eco system and its system wide accountability. NHS commissioners as must all statutory bodies, need to exhibit a leadership beyond their own remits and specific responsibilities.

GPs in the new world • Could have multiple roles- all equally important; • As leaders of consortia-as in a proactive board of an organisation. Setting the culture and style and providing knowledge on a range of clinical issues-both quality and cost effectiveness • As executives of the consortia-CEO, MD etc • As designers and leaders of specific care pathways for the consortium • Ensuring their practices are high quality, responsive and cost effective organisations • As excellent individual generalists who offer continuity of care

Primary Care Provision • Individual Practice • Federated Practices • New population based MCOs- horizontal and/or vertical. The Primary Care Home • And in the future? • New niche providers • ‘Disruptive’ technologies leading to a new approaches to provision

Primary Care Home • All primary care contractors apart from some of the ‘corporates’ however large within their professional ambit are small in NHS terms. The Royal College of General Practitioners promoting of GP Federations offers the opportunity for primary care professionals and their staff to remain local and retain the uniqueness of their current organisations. Yet concomitantly have an overarching organisation for activities that require a more centralised headquarters like function.( BMJ 335 : 585 doi: 10.1136/bmj.39342.589294.DB (Published 20 September 2007) • But the Primary Care Home offers more. A chance for professionals to integrate when that is necessary to increase their range of activities. And also to be part of an organisation real or virtual that can deliver on the potential of community based professionals by being an holistic resource for their community.

Integration is about relationships • The Primary Care Home will not succeed if this is perceived as a GP takeover. All professional skills are required if we are to improve on the often disappointing outcomes that the NHS currently provides. • “Primarily integration is about relationships between people. These relationships are not informal friendships. They have to be worked on and built professionally if clinical integration is to be meaningful and sustained through good and bad times. (C Ham. Competition and integration in the English National Health ServiceBMJ 2008;336:805-807.doi:10.1136/bmj.39532.445197.AD)

Integration • There are many forms of integration with mixed evidence that integration can produce better care(Ramsay, A., Fulop, N. and Edwards, N. Journal ofIntegrated Care 2009, vol 17(2): 3-12.). • The chief potential downside of integrated organisations is the strong possibility of ‘provider capture’ that will lessen choice and responsiveness for their citizens. At the very least such organisations must offer their public and patients choice outside of and within their services and constituent practices. That offer must be overtly transparent.

Accountability • Such community based organisations would be commissioned by the statutory NHS commissioner or indeed statutory commissioners. The NHS and Local Authority working together whether for healthcare alone or preferably also for social care. Indeed for the broader public health aspects of the whole local authority. • Accountable to their commissioner but transparently working with and accounting to their population. That being the bulwark against provider capture. • A good adage for the NHS is maybe worry less about making people accountable and more about how to help them feel responsible

Primary Care HomeWhich population do they serve? • The services offered by such an organisation must be left to local choice so an organisation could be actual or ‘virtual’. • Similarly with their defined population. The most straightforward approach is for it to be based on the GP practice population as its building block. It is a population or ‘list’ recognised over many years by patients and professionals alike. For that reason it was chosen as the population base for the Integrated Care Pilots of the Primary and Community Care Strategy of the NHS ‘Next Stage Review’ (2008) and even more fundamentally as the building block of the soon to be General Practice led Clinical Commissioning Groups. • However local agreed choice of this and other aspects must prevail. • Local ownership of new approaches is essential.

The Primary Care ‘Home’ • Population based primary care is where the needs of the individual and of the community can be met • Home for all PC providers (Pharmacists, Dentists, Optometrists), CHS and Social Care • And potentially many currently working in hospitals • Delivering on; • Improved service quality and responsiveness to patients’ individual requirements • Long Term Conditions care • Care closer to the patient’s home • The ‘home’ for extended skills and services • Service redesign which promotes clinical innovation and excellence • A reduction in unnecessary or inappropriate care leading to better value for money as clinicians prioritise to keep overall health expenditure within budget • Where bio-clinical focus and addressing the social determinants of health can be the responsibility of one provider organisation • Importance of relationship with local government and third sector

Integration, relationships and new partnerships • From formal integration as part of a spectrum that enables integration through such as joint ventures through to virtual organisations - but fundamentally with a clarity of governance and accountability. Where patient care depends on various forms of networking/partnerships, clarity of where accountability and responsibility lies is paramount. • And for providers, having a population focus can break the ‘shackles’ of too rigid a split that currently occurs between the commissioner and provider. Enabling more ‘liberation’ of all providers to be truly partners of commissioners. Enabled community based accountable population based providers that can take over some of the tasks currently undertaken by commissioners. Only actual contract setting needs to be separated in the commissioning cycle • Commissioners may need choices of integrated organisations from which to choose which does imply at least some overlapping boundaries of providers

The Primary Care Home