6th GCC Primary Health Care Conference Riyadh

Kingdom of Saudi Arabia 05 June 2007

The Effectiveness of Primary Care

Elizabeth A. Dubois Associate Director of Public Health / Health Economist

Wandsworth Teaching PCT, London, UK

Content…

• Priorities for Primary Care • Effectiveness of Primary Care• Evaluation• Conclusion

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Priorities for Primary Care

1. Prioritise Expenditure

2. Control Substitution

3. Responsiveness to Population & Accountability

4. Ability to Deliver

5. Roles of PC Team

6. Diversity & Quality

7. Demand Management

8. Education & Training in PC

Factors Influencing Care

Government

Patients

Physicians

choicesatisfaction/quality

equity

costs

standards

clinical freedom

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Prioritise Expenditure

• Agree responsibility for prioritising:

– Services

– Service spend

• Budget holding – powerful tool of change

• Professionals responsible for resource allocation

• Micro-level service development

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Facts…..

Cost-Effectiveness (Intervention cost/case):

• Telephone Call £16

• Primary Care £15

• GP with Special Interest £55

• Outpatient £150

• Day Surgery £500

• Inpatient (2ndary Care) £5000

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Facts…..

Cost-Effectiveness (Intervention cost/case):

• Telephone Call £16

• Primary Care £15

• GP with Special Interest £55

• Outpatient £150

• Day Surgery £500

• Inpatient (2ndary Care) £5000

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Control Substitution

• Shift work from secondary care to primary care

• Define primary and community care in its own right, not a residual

• Vehicle of change rather than the receiver of it

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Responsiveness to Population & Accountability

• Define core population need

– Health needs assessments

– Comparative audits

• Accountability to patients

• Accountability to the managers

• Accountability to the profession

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Ability to Deliver

• Commitment of resources

• Development of leaders

• Teambuilding

• Training in resource management

• Training in public health tasks

• No hierarchy → matrix organisation

• Right people, right skills, right time

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Roles of PC Team

• Re-examination of the role of the GP

• GPs cannot control and do all key tasks

• Re-examine the professional & clinical roles of:– Manager

– Nurse

– Pharmacist

– Psychologists

• Link public service values + private sector initiatives

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Diversity & Quality

• Grow your own vision• Build upon skills and motivation• Develop new roles• Encourage innovative partnerships (voluntary sector, private

sector, community, academic departments)• Addressing poor quality; monitor through:

• Organisational development• Investment• Audit• Performance monitoring • Professional assessment• Retraining

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Managing Demand

• One, if not the, most critical elements

• In the absence of DM, service development is irresponsible

• Increased demand due to:

– Consumer expectations

– Patient mobility

– Increasing complex problems

– Ageing population

– Advances in drugs & technology

• Address capacity issues innovatively & responsively

• Prevents service inadequacies

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Suggestions for Demand Management

• Patient education initiatives

• Non-doctors doing medical role

• Training GPs in risk management

• Training in teamwork development

• Audit of referrals / consultations w/ peers

• Timely patient information (minorities, new patients)

• Use volunteers and/or carers

• Control through monitoring & policy

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Education & Training in PC

What are we doing now? What do we want to be doing…and how shall we get there?

• Skilling

• Teambuilding

• Monitoring

• Training & development

Quality Integration

Choice

Costs

Change Organisational Behaviours

Change Physicians’ Behaviours

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Evaluation of Effectiveness in Primary Care

• Explicit responsibility for decision making– Baseline measures specific to time and place

– Consider objectives of stakeholders

• Better partnerships with other organisations– Community

– Social services

– Psychiatry

– Geriatrics

– Voluntary

– Private

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Evaluation of Effectiveness in Primary Care

• Value for money– *Key issue– Compare transaction costs– Measure need & patient outcome (but v. difficult)

• Responses to population need• Accountability to management & patient• Efficient provision of appropriate care• Evidence-based interventions• Management of demand• Equity of health care delivery• Sustainability and stability of systems• Staff retention & recruitment

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Conclusion

• Colossal agenda but real opportunity• Focus on ‘appropriateness’ to estb. good practice

– Effectiveness of interventions– Efficiency– Patient acceptability– Clinical experience– Right people, right skills, right time

• Public Health skills crucial• Managerial experience crucial• User input crucial • Clear responsibilities, particularly budgetary• Clear objectives• Robust evaluation• Sense of mutual respect for all professions working in primary and community care

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References

• Carruthers I. (1994) Total fundholding in the mainstream of the NHS. Primary Care Management. 4: 7-9.

• Fry J, Light D and Rodnick J. (1995) Reviving Primary Care: a US – UK comparison. 118-40. Radcliffe Medical Press, Oxford.

• Littlejohns P, Victor C. (1996) Making Sense of a Primary Care-led Health Service.14-28. Radcliffe Medical Press, Oxford.

• Starfield B. (1992) Primary Care: concept, evaluation and policy. Oxford University Press, New York.

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Shukran JazeelanShukran Jazeelan

Elizabeth A. DuboisElizabeth A. DuboisWandsworth Teaching PCT, LondonWandsworth Teaching PCT, London