David Colin-Thome

1. David Colin-Thome • National Clinical Director for Primary Care • GP, Castlefields, Runcorn • Honorary Professor,M.C.H.M, Manchester University • Honorary Professor, School of Health, University of Durham

2. Benefits of a first contact in primary care.(Starfield) • 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.

3. General Practice Traditional • Personal Care • Co-ordination of Care • Continuity of Care • Longitudinal care • “Gate Keeper”

4. Challenges • Transparent information-prospectus and outcomes • Allow patients the easiest path to obtain services and care • More contestability • Alternative providers • The public’s Health • Accountability

5. 21st Century Primary Care • Multiple info and access points • Continuing importance of Personal Care • Increasing emphasis on Chronic Disease Management especially of Co-morbidity • Expanding Ambulatory Care • Public Health oriented Clinicians • Active in commissioning of Secondary Care • Choice for patients and clinicians • Increasing accountability

6. The New Clinical Paradigm “The predominant acute disease paradigm is an anachronism. It is shaped on a 19th century notion of illness as a disruption of the normal state produced by a foreign presence or external trauma, e.g. infection or injury. …..Under this model acute care is that which directly addresses the threat. …. In fact, modern epidemiology shows that the prevalent health problems of today (defined both in terms of cost and health impact) revolve around chronic illness. Kane (2002)

7. The New Clinical Paradigm “While the global disease burden has been shifting towards chronic conditions, health systems have not evolved to meet this changing demand. Care is fragmented, focused on acute and emergent symptoms, and often provided without the benefit of complete medical information” WHO (2002) [1]

8. Commissioning Primary Care • nGMS • nPMS • nCommunity Pharmacy • LPS, PDS • ‘Liberating the talents’ • Community Dentistry ‘Options for Change’ • PwSI • Secondary to Primary care • Self care and self management

9. FOR PATIENTS • Choice • Voice • Control of their Care

10. Primary Care Quality (What Patients’ Value) • Availability and Accessibility • Technical Competence • Communication Skills • Interpersonal Attributes of Care • Continuity of care • Range of On-Site Services

11. “ Variations can be either warranted or unwarranted’’ Prof Al Mulley,Harvard

12. “Transparent accountability=transparent autonomy” Degeling

13. Traditional view The annual review and routine interval appointments A conveyor belt of checking and prescribed actions? New view? The Diabetes NSF Care planning ‘A care plan is at the heart of a partnership approach to care and a central part of effective care management. The process of agreeing a care plan offers people active involvement in deciding, agreeing and owning how their diabetes is to be managed’ Systematic care - A change in style?

14. Level 3 Highly complex members Intensive or Case Management Level 2 High risk members Assisted Care or Care Management Usual Care with Support Level 1 70-80% of a CCM pop Population Management:More than Care & Case Management Redesigning Processes Targeting Population(s) Measurement of Outcomes & Feedback

15. Personal health services have a relatively greater impact on severity (including death) than on incidence. As inequities in severity of health problems (including disability, death, and co-morbidity) are even greater than are inequities in incidence of health problems, appropriate health services have a major role to play in reducing inequities in health. Starfield 12/03 03-385

16. Primary care has an important role to play in reducing incidence of some health problems. Starfield 12/03 03-386

17. Primary care has a key role to play in reducing severity of most health problems. Starfield 12/03 03-387