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Darragh fahey draft v1


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Lessons from the NHS

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Darragh fahey draft v1

  1. 1. Lessons from the NHS 17 th November, 2011 National Primary Care Conference LivingHealth Clinic Dr Daragh Fahey Chief Medical Officer, UnitedHealth UK
  2. 2. It’s easier when you have money!!
  3. 3. Key Messages <ul><li>Ensure incentives for all key stakeholders are aligned with objectives </li></ul><ul><li>Support GP to develop mutual dependency between them and government policy </li></ul><ul><li>Recognise impact of destabilising good work to date with unnecessary structural changes </li></ul><ul><ul><li>What and how more important than where and whom </li></ul></ul><ul><ul><li>Be patient </li></ul></ul><ul><li>Pay for activity, patient experience, outcomes </li></ul><ul><li>Evidence based policy making, pilot first with good evaluation and then incremental change </li></ul>
  4. 4. History (1) <ul><li>Introduced in 1948 </li></ul><ul><ul><li>Significant financial pressures and disorganisation of the hospitals </li></ul></ul><ul><ul><li>GPs independent contractors paid on capitation </li></ul></ul><ul><li>1952: Danckwerts award </li></ul><ul><ul><li>Incentives awarded to doctors with intermediate size lists </li></ul></ul><ul><ul><ul><li>encourage them to take on new partners and develop group practices </li></ul></ul></ul><ul><ul><li>Later upsurge of interest in health centres </li></ul></ul><ul><ul><ul><li>group practices loan scheme </li></ul></ul></ul><ul><li>1965 Charter (relevant points) </li></ul><ul><ul><li>Better premises and equipment, more support staff, funded by gov </li></ul></ul><ul><ul><li>Incentives for skills and experience </li></ul></ul><ul><ul><li>Proper pay for work done outside the normal working day </li></ul></ul><ul><li>GPs very dependent on the NHS </li></ul>
  5. 5. History (2) <ul><li>Early 80s – greater move out of hospital (CDM) </li></ul><ul><ul><li>Increased access to sophisticated investigations </li></ul></ul><ul><li>1989: Large scale reforms proposed: </li></ul><ul><ul><li>Health insurance approach reviewed but rejected </li></ul></ul><ul><li>1990: Internal market, purc/prov split and devolved dec-making </li></ul><ul><ul><li>Health authorities manage their own budgets and buy healthcare </li></ul></ul><ul><ul><li>Fundholding </li></ul></ul><ul><ul><ul><li>Initially practices (> 11,000) could apply for own budgets for staff costs, prescribing, OPD & certain hospital services, largely elective surgery </li></ul></ul></ul><ul><ul><li>3 types (community, standard and total) by 1995 </li></ul></ul><ul><ul><ul><li>Community: to encourage smaller practices </li></ul></ul></ul><ul><ul><ul><li>Total: controlled large sums >30 m. Employed managers </li></ul></ul></ul><ul><li>GPs with pivotal role but semi-detached status still a challenge </li></ul><ul><li>Evidence on success unclear </li></ul><ul><li>Other approach: ‘locality commissioning&quot; </li></ul>
  6. 6. Pros/Cons Fundholding <ul><li>Pros </li></ul><ul><li>Harness enthusiasm of GPs to develop their practices. </li></ul><ul><li>Shorter waiting times for their patients and reduced unnecessary hospital referrals?, </li></ul><ul><li>Cons </li></ul><ul><li>Many commissioners and contractors increased transaction costs. </li></ul><ul><li>Evidence of a two tier access to health care between patients of fundholders and patients of non-fundholders. </li></ul><ul><li>Ended 1999 by labour.  </li></ul><ul><ul><li>500 PCGs (catchment circa 100,000) , took over from 4000 HAs, fundholders, and locality commissioning groups.  </li></ul></ul>Poorly Evaluated
  7. 7. History: 2000s <ul><li>PCGs encouraged to become PCTs </li></ul><ul><li>1999: Practice Based Commissioning  </li></ul><ul><ul><li>PBCs had indicative budgets </li></ul></ul><ul><ul><li>Savings to be invested locally to benefit patients </li></ul></ul><ul><ul><ul><li>Practices incentivised to provide x-rays, tests, OPD consults within own practice or commission from another </li></ul></ul></ul><ul><ul><ul><li>National tariffs: decrease risk &quot;bargain basement&quot; services. </li></ul></ul></ul><ul><ul><li>Widespread welcome </li></ul></ul><ul><ul><ul><li>Supposedly no personal financial advantages for doctors. </li></ul></ul></ul><ul><ul><li>National policy: Universal PBC but effects were patchy with GPs slow to get involved.  </li></ul></ul><ul><ul><ul><li>Primary care tsar as &quot; a corpse not fit for resuscitation.&quot; </li></ul></ul></ul>
  8. 8. History (2): 2000s <ul><li>GPs responsible for health promotion, care of acute disease, and long-term care of chronic illness    </li></ul><ul><li>Responsibility for OOHs - PCTs. </li></ul><ul><ul><li>Breakdown RCGP’s primary care model -continuity of care </li></ul></ul><ul><li>Introduction of PMS contract  </li></ul><ul><ul><li>Greater flexibility – payment for activities and outcomes </li></ul></ul><ul><ul><li>Facilitates salaried GPs </li></ul></ul><ul><ul><ul><li>employed by health authorities </li></ul></ul></ul><ul><li>Private sector - more integral </li></ul><ul><ul><li>APMS contract introduced </li></ul></ul><ul><li>Nurse Led Walk-in Centres </li></ul><ul><ul><li>Piloted in stations and shopping centre  </li></ul></ul><ul><ul><li>Minimal impact on GP workload </li></ul></ul>
  9. 9. History (3) (2000s) <ul><li>Pharmacists incentivised to expand into CDM </li></ul><ul><ul><li>Supervision of repeat prescriptions, smoking cessation etc.   </li></ul></ul><ul><li>Move to EBM culture of public accountability </li></ul><ul><ul><li>147 quality targets, 76 clinical, 20% of budget </li></ul></ul><ul><li>Greater focus on community services & and bringing GPs together </li></ul><ul><li>Polyclinics </li></ul><ul><ul><li>Combine GP and some elements of hospital care </li></ul></ul><ul><ul><li>Health & social services such as benefits support and housing advice </li></ul></ul><ul><li>Smaller GP led health centres </li></ul><ul><ul><li>Gov required every PCT to tender for on </li></ul></ul><ul><ul><ul><li>8 a.m. to 8 p.m. walk in services for registered or unregistered </li></ul></ul></ul><ul><ul><li>Conservatives ‘too top down’ and they are now unravelling </li></ul></ul>
  10. 10. Current Situation ‘Liberating the NHS’ <ul><li>Abolition of PCTs & all GPs become commissioners and hold budget (80%) </li></ul><ul><ul><li>Shadow (April 2012), Full (April 2013) </li></ul></ul><ul><li>‘ No decision about me without me’ </li></ul><ul><li>£20bn efficiency/savings target over next 4 years </li></ul><ul><li>Huge opposition: BMA, College of Nursing, opposition parties, Lib Dems & GPs </li></ul><ul><ul><li>Education of GPs as commissioners </li></ul></ul><ul><ul><li>Time for patients vs time as commissioners </li></ul></ul><ul><ul><li>Privatisation of NHS* </li></ul></ul><ul><ul><li>Bureaucracy (transition cost of £1.7bn, CGs increasing from 163-521 ) </li></ul></ul><ul><ul><li>Making government less responsible (SOS ‘duty to provide’) </li></ul></ul><ul><ul><li>Choice VS quality and consistent, seamless healthcare </li></ul></ul><ul><li>Very slow to get legislation approved (now at normal committee stage in Lords) </li></ul><ul><li>Unlikely that GPs will be forced to become commissioners </li></ul><ul><ul><li>PCT Clusters housing old PCT staff </li></ul></ul><ul><li>New GP contract: replace some old quality and productivity indicators with those focussing on reducing the number of 'avoidable' A&E attendances. </li></ul>* conservatives had committed to developing a fully privatised NHS with social insurance scheme in 2002.
  11. 11. Still a long way to go… <ul><li>75% of GPs call for Health Bill to be withdrawn! </li></ul>
  12. 12. Dutch HealthCare System <ul><li>From 2006: Dual funded system </li></ul><ul><ul><li>All primary and curative care (i.e. the family doctor service and hospitals and clinics) is financed from private obligatory insurance. </li></ul></ul><ul><ul><li>Long term care for the elderly, the dying, the long term mentally ill etc. covered by social insurance funded from earmarked taxation. </li></ul></ul><ul><li>Private insurance companies must offer core universal insurance package (includes prescription costs) </li></ul><ul><ul><li>Fixed price for all (irrespective of age, healthy or sick). </li></ul></ul><ul><ul><li>Financed into a regulator fund </li></ul></ul><ul><ul><ul><li>50% from payroll taxes paid by employers </li></ul></ul></ul><ul><ul><ul><li>5% from government </li></ul></ul></ul><ul><ul><ul><li>45% premiums paid by the insured directly to the insurance company . </li></ul></ul></ul><ul><li>Regulator sees claims - can redistribute the funds its holds on the basis of relative claims made by policy holders. </li></ul><ul><ul><li>Insurers with high payouts receive more from regulator </li></ul></ul>
  13. 13. What has changed? <ul><li>Old situation </li></ul><ul><li>Patients (60%):capitation </li></ul><ul><li>Privately insured (40%): </li></ul><ul><ul><li>fee per consultation </li></ul></ul><ul><li>From January 2006 </li></ul><ul><li>Uniform insurance system </li></ul><ul><li>Fee per consultation (€9) </li></ul><ul><li>Capitation (€52) </li></ul><ul><li>Fees for specific services </li></ul>
  14. 14. Lessons Learned <ul><li>Crucial to get incentives right (QOF) </li></ul><ul><ul><li>Focus on activities, user experience & outcomes </li></ul></ul><ul><li>Avoid one size fits all </li></ul><ul><ul><li>Don’t mandate the solution e.g GP-Led Health Centres </li></ul></ul><ul><li>Develop mutual dependency between gov & GPs </li></ul><ul><li>GPs as commissioners can work </li></ul><ul><ul><li>Beware two tiered system (all should participate) </li></ul></ul><ul><ul><li>Provide more training as commissioners </li></ul></ul><ul><ul><li>Beware sacrificing patient care </li></ul></ul><ul><li>Evidence based policy changes </li></ul><ul><li>Form versus function </li></ul><ul><ul><li>Avoid reinventing the wheel </li></ul></ul><ul><ul><li>Be patient </li></ul></ul>
  15. 15. Is Restructuring the Answer?
  16. 16. We’ve all got financial challenges! - cooperate & value each other’s contributions Email : [email_address]