September 24th 2013

1. Developing a Primary Care Network in PHW – How does primary care support public health improvement? September 24th 2013 Primary Care Network Workshop 24 9 13 Paul Myres and Sally Venn

2. What are we starting to answer today? How can Public Health Wales impact on the effective delivery of primary care in Wales so as to improve population health outcomes (and avoid harm)? How can teams within Public Health Wales support the delivery of the organisation’s key objectives? Primary Care Network Workshop 24.9.13

3. Definitions Public health ‘The science and art of preventing disease, prolonging life and promoting health through the organised efforts of society’ Primary Care Network Workshop 24 9 13

4. Primary care Essential care; based on practical, scientifically sound and socially acceptable method and technology; universally accessible to all in the community through their full participation; at affordable cost and geared towards self-reliance and self-determination Primary Care Network Workshop 24 9 13

5. Bevan Principles – what should NHSWales be providing in 2013 • a service that values people • getting the best from the resources available • a need to ensure health is reflected in all policies • minimising the effects of disadvantage on access and outcome • a high quality service that maximises patient safety • patient and public accountability • achievement of continuous performance improvement universal access, based on need comprehensiveness, within available resources services free at the point of delivery a shared responsibility for health between the people of Wales and the NHS Primary Care Network Workshop 24 9 13

6. The NHS in 2013 the reality Demand exceeding supply Fragmentation of care Poor continuity of care Artificial divides between health, social, primary and secondary care To much focus on specialisms….not enough on generalism Not enough use of e-health Unacceptable health inequalities And….. Primary Care Network Workshop 24 9 13

7. The population • More living longer • More obese • Less active • More morbidities and LTCs • Being harmed by medical interventions • Have higher expectations and expressing more needs • More tech savvy • Receiving unequal care Primary Care Network Workshop 24 9 13

8. Primary care oriented health systems • Generalists improve health outcomes • Strong primary care systems improve population health and reduce health inequities • The supply of specialists does not appear to improve population health outcomes Primary Care Network Workshop 24 9 13

9. Primary care Is NOT just about providing biomedical services close to home It provides • Longitudinal person centred care (not disease focused) • A first point of contact for most health problems • Comprehensive holistic care in the context of family and community • Coordination of care for individuals • Universal coverage Primary Care Network Workshop 24 9 13

10. Primary care in the NHS Independent contractors • General Medical Services – GPs and nurses • Core & Enhanced services; QoF; • Community Pharmacies • Enhanced services • General Dental Services • Optometry Services Welsh Eye Care Initiative Health Boards • Community nurses; health visitors; school nurses, dietitians etc Primary Care Network Workshop 24 9 13

11. Primary care workforce • In Wales, there are • 3000 GPs • 710 community pharmacies, • over 3,400 nurses, midwives and health visitors • more than 1000 dentists • 852 ophthalmic practitioners Primary Care Network Workshop 24 9 13

12. Primary care ‘reach’ • Over 90% of patient contacts with the NHS take place in primary care. • 94% of the population visits a pharmacy at least once a year • Each adult visits a pharmacy on average 12 times a year • 55.7% population treated by a dentist in 24 months before 31.03.12 Primary Care Network Workshop 24 9 13

13. Care across the life course Prevention Early recognition and treatment Ongoing support Primary Care Network Workshop 24 9 13

14. Primary care services Health Protection Health Improvement Health care Quality Primary Care Network Workshop 24 9 13

15. Health protection • Immunisation programs • Childhood - measles • Seasonal flu • Specific at risk groups –Hep B/ BCG • Outbreaks, epidemics and pandemics • Surveillance • Rapid response –measles, pandemics • Emergency responses • Major incidents - floods Primary Care Network Workshop 24 9 13

16. Health Improvement • Patient empowerment • Signposting; information; health literacy • Motivational interviewing; brief interventions • Risk communication • Implementing public health programmes • Smoking cessation • Exercise schemes • Obesity / healthy eating • Mental health; substance misuse; alcohol • Worklessness; Back pain • Breast feeding Primary Care Network Workshop 24 9 13

17. Health Intelligence Information based planning and improvement at practice, cluster, LA or LHB level • Disease prevalence (QOF) • Audit+ data Practice Profiling / Quality Assurance Research Primary Care Network Workshop 24 9 13

18. Healthcare quality • Care pathways • Standards of service provision • Clinical Governance Self Assessment Tool • Audits • Service specifications for enhanced services • GMS, GDS, GOS, Community Pharmacy contract regulations • Performance of individual practitioners • Professional registration and regulation • Training Standards • Appraisal & Revalidation • Appropriate response to concerns • National, equitable policies Primary Care Network Workshop 24 9 13

19. Primary care practitioners Deal with undifferentiated problems Provide universal access to first contact care Provide comprehensive compassionate holistic care Offer continuity of relationship Coordinate services around the needs and shared decisions of the patient Primary Care Network Workshop 24 9 13

20. Primary care practitioners Deliver health promotion and disease prevention Act as gatekeeper and navigator ensuring effective resource utilisation Be independent advocates for patients Be part of their patients’ communities supporting community development Primary Care Network Workshop 24 9 13

21. Primary Care Network Workshop 24 9 13

22. Investment in PHC in Wales Total NHS spend by primary and secondary care Source: Kathrin Thomas with the Program Management Unit, Public Health Wales Primary Care Network Workshop 24 9 13

23. Possible NHS solutions • Use appropriate technology • Integrate health and social care • Avoid single disease silos • Promote empowerment • Avoid medicalising society • Invest for population outcomes • Prioritise high impact interventions Primary Care Network Workshop 24 9 13

24. Integrated Health Boards Opportunities Threats Money Secondary care dominance Lack of levers Inverse Care Law Decreased clinical engagement System inertia Skills gap Public health not in Local Government • New population level: Clusters/ Localities • Devolved decision-making level • Integration with social care • Whole system approaches • Community oriented primary care • Public health in NHS Primary Care Network Workshop 24 9 13

25. Increasing public health impact • Reorientate Health Services • Empowerment; self management • Avoid inappropriate use of secondary care services • Drive safety and quality • Safe systems • Avoid inappropriate use of secondary care services • Primary care data • Collect and collate • Feedback Primary Care Network Workshop 24 9 13

26. How do we make this happen? • Collaboration • Coordination • Communication • Coproduction In the context of: Strong clinical leadership Increased Capacity Primary Care Network Workshop 24 9 13

27. Conclusion • The contribution of health care services towards public health outcomes is largely through Primary Health Care • It works by prevention, advocacy, health promotion, helping change behaviours, screening, risk identification and management, and ..... just by being there..... • PHC could have a powerful leadership and advocacy role for transformation, currently underused in Wales. • We can support improvement in effectiveness Primary Care Network Workshop 24 9 13