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Gestió de l’atenció hospitalària especialitzada al Regne Unit (apunts)


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Jornades ACEBA 2013
Apunts i bibliografia

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Gestió de l’atenció hospitalària especialitzada al Regne Unit (apunts)

  1. 1. Gestió de l’atenció Hospitalària al Regne Unit (APUNTS) General medical services is the name used in the United Kingdom to describe the medical services provided by General Practitioners (GPs or family doctors) who, in effect, run private businesses independently contracting with the National Health Service. Proposals to make GPs salaried professionals were rejected by the profession in 1948 The defining feature of PMS agreements is their local nature. Unlike GMS contracts, they are negotiated between the PCO and the practice, and are not subject to direct national negotiations between the Department of Health and the General Practitioners Committee of the BMA. Nevertheless, the national GMS contract, which came into force on 1 April 2004, had a strong impact on PMS policy and on the contents of PMS agreements. 1960s – Contractual improvements In 1966 a new contract improved pay and conditions for GPs, instituting a maximum list size of 2,000 patients and providing resources for professional education, improvement of premises and hiring of support staff. 1970s – Professionalisation The creation of the Royal College of General Practitioners, in 1972, gave GPs a official representative body for the first time. After years of concern about the adequacy of GP training, from 1976 three-year postgraduate training programmes became mandatory. 1990sGP fundholding (VOLUNTARI) allowed GPs to take on responsibilities for commissioning services on their patients’ behalf, creating an incentive for GPs to become more involved with the wider health system. Before this, local health authorities organised both the planning and the delivery of services for their patients. In 1991 the Conservative government split this function by creating 'purchasers' and 'providers' in the local health system (NHS and Community Care Act 1990). It created two models of commissioning – one based on health authorities, and the other based on general practice. Under GP fundholding GPs held real budgets with which they purchased primarily non-urgent elective and community care for patients; they had the right to keep any savings and had the freedom to deliver new services. The aim was to give GPs a financial incentive to manage costs and to apply some competitive pressure to hospital providers. Some GP practices came together in consortia, creating larger organisations to pool financial risk and share resources. From 1994 the total purchasing pilot scheme (TPP) allowed general practices – either individually or in groups – to commission all services for their patients, though most were highly selective in what they chose to purchase Dr  Josep  Vidal-­‐Alaball     1  
  2. 2. Many practices joined, covering just over 40% of the population and controlling around 8% of the NHS budget for hospital and community health services. 1997 New Labour under Tony Blair is elected with a promise to scrap the internal market and GP fundholding, and to replace competition with collaboration. 2000s – After the NHS staggers under the pressures of a winter hospital crisis, Labour responds with an ambitious "NHS plan" and massively increases investment Primary care trusts are created to purchase healthcare on behalf of GPs. It re-adopts the principles of competition Quality and Outcomes Framework (QOF) The 2004 GP contract represented a new relationship between GPs and the NHS, putting an increased emphasis on performance-related pay, as measured by the QOF. Competition in primary care was encouraged through enabling patient choice of general practice, scrapping practice boundaries, and introducing independent- sector competition through ‘any willing provider’ contracts. 2013 Creation in England of NHS Commissioning Board and Clinical Commissioning Groups to replace SHA's and PCT's. DADES: In 2009, there were 32,111 full-time equivalent (FTE) GPs and 72,153 FTE practice staff working in general practice in England across 8,228 practices (not including GP registrars or GP retainers). In 2008 there were 300 million general practice consultations, 62 per cent of which were undertaken by GPs. GPs made 9.3 million referrals to secondary care, suggesting that around one in 20 GP consultations results in a referral to secondary care. That means 19 out of 20 GP consultations, plus consultations with other general practice staff, were resolved within general practice by health professionals with generalist skills. Structure of GP Pay - NHS 85%, Private 15% NHS Basic work 20% 50% 15% Basic Practice Allowance Capitation Payments Item of Service (imms, maternity, minor ops, 5% Targets – Smears and childhood vaccinations contraception) Dr  Josep  Vidal-­‐Alaball     2  
  3. 3. 10% Miscellaneous (training grant, premises, committees) Staff Reimbursements – 75-80% of salaries covered by staff budget Private Medicals, reports, drug trials Primary care capitation payments in the UK Spending on GP services has dropped over the past ten years, while investment in hospitals has risen sharply, showing the Department of Health’s plans to shift more care into the community and cut costs are in reverse. The report from the Nuffield Trust reveals spending on GP services has dipped by 0.2% a year over the last five years, with no additional investment into general practice since 2005. This compares with spending on secondary care jumping 40.1% over the same period - an equivalent of an average increase of over 5% a year. Clinical commissioning: What can we learn from previous commissioning models? In England, commissioning was primarily carried out by 152 primary care trusts (PCTs), which in 2009/10 received £80 billion (more than 80 per cent of the NHS budget) to purchase care for an average population per PCT of 300,000. A total of 211 CCGs will, from 1 April 2013, be responsible for £65 billion of the £95 billion NHS commissioning budget _Clinical_commissioning_groups_April_2013.pdf Clinical Commissioning Boards: autorització, regulació CCG. National body, which has been given a formal mandate to oversee the commissioning of health services in England MEMBERSHIP: CCG's governing body includes GPs, hospital doctors, a nurse and lay members representing the public. They are independent statutory bodies, led by their members: the GP practices in their area Dr  Josep  Vidal-­‐Alaball     3  
  4. 4. All general practices will be required to become members of a clinical commissioning group that will hold real budgets and commission the majority of NHS services for their patients (including elective hospital care, rehabilitative care, urgent and emergency care, most community health services, and mental health and learning disability services). A new NHS Commissioning Board (NCB) will calculate practicelevel budgets and allocate these to CCGs 1. First, they are responsible for commissioning secondary and community care services for their local population. 2. Second, they have a role in supporting quality improvement in general practice. Clinical Commissioning Groups are groups of General Practices that work together to plan and design local health services in England. They do this by 'commissioning' or buying health and care services including: • • • • • Planned hospital care Urgent and emergency care Rehabilitation care Community health services Mental health and learning disability services These two roles are closely connected – it is not possible to commission secondary care effectively without also considering the way patients are supported in primary care Thus we can expect that many CCGs will look to encourage the development of new models of primary care to support their plans to shift care out of hospital and enable better coordinated care. It is, however, still unclear as to how CCGs will be able to exert influence over the services delivered by the practices that are members of the CCG – CCGs do not contract with practices for their core services (that is the role of NHS England) and they do not have direct legal authority over the clinical behaviour of practices As well as overseeing Clinical Commissioning Groups, NHS England commissions some services itself. These are: • • • • General Practice Pharmacy Dentists Specialist services (i.e. those required by a limited number of people) Under the terms of the regulations, commissioners are expected to consider whether more competition and choice might improve quality, although the same regulations also allow commissioners to award a contract without competition if the commissioner is satisfied that only one provider is capable of delivering that service. Dr  Josep  Vidal-­‐Alaball     4  
  5. 5. Commissioning support services. To carry out some of the commissioning functions for them across local authority boundaries. However, final commissioning decisions must be made by the CCG and cannot be delegated. OPORTUNITAT CCGs have a real opportunity to get clinical expertise into the heart of decisionmaking Identifying population needs and designing the care pathways that can reduce costs and improve patient care locally. From day one it will be critical for new consortia to identify the models of care and prevention that are needed most to provide better, seamless care throughout the patient journey. Clinical commissioning groups will need strong clinical engagement and innovation to develop preventative care pathways to address health needs of those most at risk. This will require, for example, new models for managing long-term conditions, supporting the delivery of self-care and working collaboratively with patients to allow them to make full use of assistive technology. Engaging the right organisations and stakeholders that will help deliver consortia’s vision to improve health outcomes for the local population. Clinical commissioning groups will need to build the right multi-professional relationships Dr  Josep  Vidal-­‐Alaball     5  
  6. 6. across primary, secondary, social care providers, local authorities and undertake strong public consultation exercises, to deliver the service changes they wish to see. In bringing about this change CCGs will have to enter a dialogue with their local communities. Trust and integrity will underpin this dialogue and perhaps this is where the clinicians of the new CCGs may have an advantage, in the eyes of the public, compared to the previous primary care trust managers TRANSPARENCY: CCGs are public bodies and are required to hold their meetings in public and publish minutes. They also have to publish details of contracts with health services. EXEMPLE: SPECSAVERS Network of over 440 Hearing Centres across the UK We have a proven record of successfully working with the NHS over many years, providing eye tests, diabetic retinal screening, hearing assessments and digital hearing aids to a number of Primary Care Trusts across the UK. For CCG’s and GPs looking to commission Adult Hearing Services, we can bring hearing care closer to your patients' homes. With appointment times to suit their lifestyle, Specsavers can offer a comprehensive and cost-effective service, with hearing assessments within two weeks of referral, and hearing aids supplied and fitted to NHS patients within five weeks of referral. But it doesn't stop there; our service ensures up to three-years' patient aftercare too. GPs face pressure from patients after Specsavers markets its NHS audiology service The leading commercial eyecare provider Specsavers has been criticised for directly marketing its NHS funded hearing care services to patients, amid fear of a surge in demand that could destabilise NHS finances The company has secured more than 30 contracts to provide community audiology services across England Specsavers has sent out leaflets to patients, featuring the NHS logo, urging them to ask their GP to refer them to Specsavers for free hearing tests, free digital hearing aids, and free aftercare. The company has also placed advertisements for its NHS services in newspapers and on buses. Dr  Josep  Vidal-­‐Alaball     6  
  7. 7. GP commissioners are concerned that the marketing drive may stimulate unnecessary demand and hamper their efforts to keep increasingly tight NHS finances under control. Ways of working that support CCGs and NHS England to secure high quality care for all, now and for future generations Problems CCG No experience:­‐for-­‐ccgs/­‐content/uploads/2012/07/comm-­‐maternity-­‐ services.pdf Managers from the defunct primary care trusts are being rehired to lead the new clinical commissioning groups made up of GPs. Of 81 CCGs to have made appointments, 50 have chosen a manager. The act has had many opponents and should Labour win the next election in 2015 it has said it will transfer the commissioning of healthcare to local councils. So the new CCGs face the prospect that their lifespan could turn out to be shorter than their gestation. “the more it changes, the more it’s the same thing” When we consider the recent reorganisation, we have to remember there is a difference between change and improvement; all improvement is change but not all change is an improvement. Time will tell whether we are on a path to improvement or merely change. Although the changes on 1 April brought about a shift of power from managers to clinicians, the next more radical shift needs to be from clinicians to the public. OTHER: A day in the life of ... a CCG chief officer Key statistics on the NHS NHS Nene Clinical Commissioning Group Dr  Josep  Vidal-­‐Alaball     7