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Divergence in Primary Care

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What can we learn from Scotland and England?

What can we learn from Scotland and England?

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  • 1. Divergence in primary care What can we learn from Scotland and England? Kate O’Donnell General Practice & Primary Care, University of Glasgow.
  • 2. Population size. London 7.43 million North West 6.83 million East of England 5.49 million West Midlands 5.33 million Scotland 5.12 million Yorkshire & The Humber 5.04 million South West 5.04 million East Midlands 4.28 million South East Coast 4.19 million South Central 3.92 million Wales 2.97 million North East 2.55 million Northern Ireland 1.74 million
  • 3. Rurality. Number of people per hectare by Council area (2001 Census).
  • 4. Scotland and deprivation. Directly standardised mortality rates per 1,000 population, 1990/92, by country and deprivation quintile.Source: PHIS Chasing the Scottish Effect 2001, Glasgow Centre forPopulation Health
  • 5. Long-term unemployment (% of unemployed aged16-74).
  • 6. LLTI across the UK.Northern Ireland 19.5Wales 19.4North East 19.4North West 17.8Scotland 17.3Yorkshire & The Humber 16.6West Midlands 16.0UK 15.7East Midlands 15.4England 15.2London 15.1South West 14.0East 13.3South East 12.6% population (age-standardised), 2001 Census.
  • 7. Scotland and health.% of people reporting limitinglong-term illness by Council area,2001 Census
  • 8. Primary care structure. Single- Small Medium Large Total handed (2 – 3 (4 – 5 (6+ GPs) GPs) GPs) England 2504 2791 1996 1466 8757 (29) (32) (23) (16) Scotland 175 370 290 212 1047 (17) (36) (27) (21) Wales 105 170 158 75 508 (21) (33) (31) (14) NI 71 190 78 32 371 (19) (51) (21) (8) RCGP Information Sheet No 4, May 2005.
  • 9. GP numbers % increase from 1985 – 2003: England 10.9. Scotland 8.7. Wales 3.4 NI 5.2Average practice list size (under nGMS Contract):England 5891.Scotland 5095.Wales 5885. RCGP Information Sheet No 4, May 2005.
  • 10. The similarities. Aging population Recruitment and retention Long term conditions Skill mix Rising demand for nGMS care contract Structural re-organisations
  • 11. GMS contract.UK-wide contract.Patients registered with practices not with individual GPs.Essential & enhanced services.Opt-out from out-of-hours responsibility.Greater emphasis on incentivised care. Quality and Outcomes Framework.
  • 12. Quality & OutcomesFrameworkTotal of 1050 points.Care incentivised across 19 clinical areas, worth 655 points.Focus on chronic disease.In 2006/07 – each point worth £124.
  • 13. Structural GP and practice characteristicsin four UK countriesVariable England Wales Scotland Northern IrelandNumber of practices 8542 501 1056 366Number of whole-time equivalent (WTE) 31523 1816 3782 1078GPsAverage registered population 6401 6171 5249 5361Average number of GPs per practice 3.7 3.6 3.6 3.0Registered population per WTE GP 1666 1674 1343 1663Single-partner practices (%) 23 19 16 19Practices with six or more GPs (%) 21 16 20 9*All figures for 2004-05 with the exception of Northern Ireland 2003-4[12]McLean et al. BMC Health Services Research 2007 7:74 doi:10.1186/1472-6963-7-74
  • 14. Average percentage achievement by indicatorcategory and countryCategory England Scotland Wales Northern IrelandPayment qualitySimple (14 measures) 93.4 93.7 92.7 94.4Complex (3 measures) 80.4 84.5 75.3 81.6Outcome (9 measures) 72.3 74.7 72.0 76.3Treatment (5 measures) 82.4 83.4 79.8 85.4Population achievementSimple (14 measures) 91.9 92.6 91.6 93.4Complex (3 measures) 76.4 79.1 71.9 77.7Outcome (9 measures) 68.2 69.8 67.1 72.2Treatment (5 measures) 72.6 72.8 68.3 76.4McLean et al. BMC Health Services Research 2007 7:74 doi:10.1186/1472-6963-7-74
  • 15. Prevalence rates reported in the Quality andOutcomes Framework in the four UK countriesPrevalence (%) England Scotland Wales Northern IrelandCHD 3.59 4.61 4.20 4.28Stroke 1.43 1.80 1.69 1.50Hypertension 11.32 11.85 12.70 10.60Diabetes 3.45 3.50 3.90 3.00Ratio to EnglandCHD 1 1.28 1.17 1.19Stroke 1 1.26 1.18 1.05Hypertension 1 1.05 1.12 0.94Diabetes 1 1.01 1.13 0.87McLean et al. BMC Health Services Research 2007 7:74 doi:10.1186/1472-6963-7-74
  • 16. Governance & incentives.QOF monitoring appears more rigid in England.Scotland: QOF verification, but no sanctions.Exploring how GMS governance is enacted.Impact of incentivised on practices and on patients.Suggestion that enhanced services being developed to met localhealth needs, but may lead to increased monitoring.
  • 17. The differencesScotland. England.Integrated Health Boards. SHAs, PCTs, Foundation hospitals.Managed clinicalnetworks. Practice-based commissioning.NHS 24 front-ending oohcalls. Mixed economy in ooh service provision.Traditional ooh delivery inPC. “Hard” monitoring in QOF.“Soft” monitoring in QOF. Less emphasis on prevention/public health. De-centralisation inprimary care – health and Connecting for Health.social care. Payment by results.Anticipatory careprogramme.
  • 18. Increasing patient & publicinvolvement.24-hour nurse-ledtelephone triage service(NHS 24).Reducing inequalities.Banning tobaccoadvertising.Setting national standards& streamliningaccountability processes.Unified NHS Boards.Reduce waiting times.
  • 19. Services local to need.Preventative, anticipatory care.Greater integration – primaryand secondary care; primary,community & social care.Optimise use of newtechnologies e.g. ehealth.Support new skill mix options.Patient & public involvement.Tackling inequalities.Supporting long-term conditions.
  • 20. Anticipatory care programme toreduce health inequalities: KeepWell.Support self-care for long-termconditions.Establish health & social careservices in communities:Community hospitals; CommunityHealth Partnerships.Reduce waiting times.Electronic Health Record andEmergency Care Summary.Streamline unscheduled care.Support remote & rural healthcare.
  • 21. CHPs/CHCPs.New organisations developed to manage a wide range of communitybased health services.Bring together primary care (including general practice), community careand social care.Co-terminous with local government boundaries.41 established.Priorities: A shifting of the balance of care to more local settings and Improvement in the health of local people.
  • 22. Reducing inequalities in health.
  • 23. Keep Well.Targeting hard-to-reach populations: 45 – 64 year olds in most deprived communities.Improve reach and engagement.Once engaged – improved primary prevention. improved secondary prevention.Piloted in 5 CHPs; 7 more later this year.Over 90 practices involved.What will be the outcome for patients; for practices; for the wider NHS?
  • 24. Where dowe go fromhere?
  • 25. Conclusions.Scotland continues to reject a marketised approach to healthcare.Greater move towards health and social care integration.Anticipatory care high on agenda.Governance and monitoring low-key, but may not remain likethat.Need to address twin issues of inequality and deprivationcontinues to influence Scottish health policy.
  • 26. We Americans live in a nation where the medical-care system issecond to none in the world, unless you count maybe 25 or 30little scuzzball countries like Scotland that we could vaporize inseconds if we felt like it.Dave BarryUS columnist & humorist (1947 - )

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