What can we learn from Scotland and England?

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 for
Population Health

5. Long-term unemployment (% of unemployed aged
16-74).

6. LLTI across the UK.
Northern Ireland 19.5
Wales 19.4
North East 19.4
North West 17.8
Scotland 17.3
Yorkshire & The Humber 16.6
West Midlands 16.0
UK 15.7
East Midlands 15.4
England 15.2
London 15.1
South West 14.0
East 13.3
South East 12.6
% population (age-standardised), 2001 Census.

7. Scotland and health.
% of people reporting limiting
long-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 5.2
Average 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 & Outcomes
Framework
Total 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 characteristics
in four UK countries
Variable England Wales Scotland Northern Ireland
Number of practices 8542 501 1056 366
Number of whole-time equivalent (WTE)
31523 1816 3782 1078
GPs
Average registered population 6401 6171 5249 5361
Average number of GPs per practice 3.7 3.6 3.6 3.0
Registered population per WTE GP 1666 1674 1343 1663
Single-partner practices (%) 23 19 16 19
Practices 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 indicator
category and country
Category England Scotland Wales Northern Ireland
'Payment quality'
Simple (14 measures) 93.4 93.7 92.7 94.4
Complex (3 measures) 80.4 84.5 75.3 81.6
Outcome (9 measures) 72.3 74.7 72.0 76.3
Treatment (5 measures) 82.4 83.4 79.8 85.4
'Population achievement'
Simple (14 measures) 91.9 92.6 91.6 93.4
Complex (3 measures) 76.4 79.1 71.9 77.7
Outcome (9 measures) 68.2 69.8 67.1 72.2
Treatment (5 measures) 72.6 72.8 68.3 76.4
McLean et al. BMC Health Services Research 2007 7:74 doi:10.1186/1472-6963-7-74

15. Prevalence rates reported in the Quality and
Outcomes Framework in the four UK countries
Prevalence (%) England Scotland Wales Northern Ireland
CHD 3.59 4.61 4.20 4.28
Stroke 1.43 1.80 1.69 1.50
Hypertension 11.32 11.85 12.70 10.60
Diabetes 3.45 3.50 3.90 3.00
Ratio to England
CHD 1 1.28 1.17 1.19
Stroke 1 1.26 1.18 1.05
Hypertension 1 1.05 1.12 0.94
Diabetes 1 1.01 1.13 0.87
McLean 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 local
health needs, but may lead to increased monitoring.

17. The differences
Scotland. England.
Integrated Health Boards. SHAs, PCTs, Foundation
hospitals.
Managed clinical
networks. Practice-based
commissioning.
NHS 24 front-ending ooh
calls. Mixed economy in ooh
service provision.
Traditional ooh delivery in
PC. “Hard” monitoring in QOF.
“Soft” monitoring in QOF. Less emphasis on
prevention/public health.
De-centralisation in
primary care – health and Connecting for Health.
social care.
Payment by results.
Anticipatory care
programme.

18. Increasing patient & public
involvement.
24-hour nurse-led
telephone triage service
(NHS 24).
Reducing inequalities.
Banning tobacco
advertising.
Setting national standards
& streamlining
accountability processes.
Unified NHS Boards.
Reduce waiting times.

19. Services local to need.
Preventative, anticipatory care.
Greater integration – primary
and secondary care; primary,
community & social care.
Optimise use of new
technologies e.g. ehealth.
Support new skill mix options.
Patient & public involvement.
Tackling inequalities.
Supporting long-term conditions.

20. Anticipatory care programme to
reduce health inequalities: Keep
Well.
Support self-care for long-term
conditions.
Establish health & social care
services in communities:
Community hospitals; Community
Health Partnerships.
Reduce waiting times.
Electronic Health Record and
Emergency Care Summary.
Streamline unscheduled care.
Support remote & rural health
care.

21. CHPs/CHCPs.
New organisations developed to manage a wide range of community
based health services.
Bring together primary care (including general practice), community care
and 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.

23. Reducing inequalities in health.

24. 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?

25. Where do
we go from
here?

26. Conclusions.
Scotland continues to reject a marketised approach to health
care.
Greater move towards health and social care integration.
Anticipatory care high on agenda.
Governance and monitoring low-key, but may not remain like
that.
Need to address twin issues of inequality and deprivation
continues to influence Scottish health policy.

27. We Americans live in a nation where the medical-care system is
second to none in the world, unless you count maybe 25 or 30
little scuzzball countries like Scotland that we could vaporize in
seconds if we felt like it.
Dave Barry
US columnist & humorist (1947 - )