Upload
neil-jackson
View
218
Download
0
Tags:
Embed Size (px)
Citation preview
MIGRAINE IN PRIMARY CARE ADVISORS
Implications of the new GP contract to headache management
Overview
• Review of the new GP contract
• Identifying opportunities in the new contract
• Designing audits based on targets in the contract
Review of the new GP contract
Overview
• More flexible service provision
• Support of human resources and infrastructure modernisation
• Investing in primary care services
• Rewarding clinical and organisational quality
• Providing better services for patients
• Implementation
More flexible service provision
• Address issues of practice workload• Service categorisation
– Essential services: compulsory– Additional services: usually provided– Enhanced services: specialist and optional
• PCOs ensure patient access to services not compromised
• GPs have balance between work and personal commitments
• PCOs take full responsibility for out-of-hours services
• PCOs can provide or commission services
Support of human resources and infrastructure modernisation
• Improve working lives of GPs– 3-module approach: skills, knowledge and experience– Reward experience– Support work / life balance
• Enhance practice management• Additional support for rural and remote practices• Practice infrastructure modernised
– New / modernised premises– Investment in information management and technology
(IM&T)
• Flexible service provision by supported individuals
Human resource development
• New career structure– Skills development, primarily for newly qualified
GPs (skills rather than titles)– Special interest development – e.g. GPwSI
services– Clinical leadership – e.g. education, mentoring,
governance, appraisal
• Learning and personal development supported through protected time– Practices to develop support systems
• Proper funding of appraisals in PCOs
Supporting practice staff: nurses
• Quality framework applies to practice team, rather than the GP in isolation
• Nurses supported to take on advanced and specialised roles– Clinical supervision and appraisal– Access to professional development and
IM&T– Roles in first contact care, chronic disease
management and preventive services
Supporting other practice staff
• Support practices to develop greater skill mix– Registered nurses– Pharmacists– Allied health professionals
• Professionals work at all levels as part of the practice team– Involved in practice decision making that
impacts on their work
Investing in primary care services
• Guaranteed level of resources allocated through PCOs
• Average practice income will rise• Practices have flexibility in how they spend
money received• Money will flow according to patient need• Investment in advanced services• Separate allocations to premises• Definition of pensionable pay broadened
– Real benefit
Service categorisation
Essential services (compulsory)• Management of ill patients back to
health, reflecting patient choice• General management of the
terminally ill• Management of chronic disease in
discussion with the patient
Service categorisation
Additional services (opt out possible)• Cervical screening• Contraception• Vaccinations and immunisations• Child health surveillance• Maternity services• Minor surgery
Service categorisation
Enhanced services (specialist and optional)
• Essential/advanced services delivered to a higher standard– e.g. extended minor surgery
• More specialist services– GPwSIs– Primary-secondary care interface– Specific local needs– Piloting innovative services
Out-of-hours service
Possible options• NHS Direct / 24• GP co-ops• NHS walk-in centres• Practice partnerships• Paramedics • Pharmacists• A&E departments with GPs and primary care
nurses• Commercial deputising services• Social work services
Rewarding clinical and organisational quality
• Major focus on quality and outcomes• Rewards practices for the quality of
care delivered to patients• The framework
– Clinical domain– Organisational domain– Patient experience domain– Additional services domain
• Implemented by annual review, including a practice report and a visit by the PCO
Clinical domain
Essential services but provided at enhanced level
• CHD, including LVD• Stroke and TIA• Hypertension• Hypothyroidism• Diabetes• Mental health• COPD• Asthma• Epilepsy• Cancer
No headache!
Indicators for each domain
• Based on best available evidence– But evidence may change and has to be
updated• Number kept to a minimum• Data should be useful for patient care
– Not for audit only• Obtainable from existing practice
systems
Clinical indicators
1. Structure: Medical records
2. Process: Diagnosis / initial management
3. Outcome: Ongoing management
Organisational domain
• Records and information• Communicating with patients
– Only two questionnaires currently approved
• Education and training• Medicines management• Clinical and practice management
Patient experience domain
• Patient survey• Consultation length
• Major opportunity for headache?
Additional services domain
• Cervical screening• Child health surveillance• Maternity services• Contraceptive services
Providing better services for patients
• Services designed around patients’ needs• Patient Services Guarantee ensure patients
continue to receive primary care services• Patients register with practice rather than GP
– But retain the choice to see an individual GP• Empowering patients to manage their own
conditions– Improving public education– Developing the skill mix across primary care– Developing ‘expert patient’ schemes– Working with community pharmacies
Benefits to patients
• Increased resources available• Allocation of resources according to patient
need• Choice of practice and practitioner• Patient Services Guarantee• Aim for higher quality services• Feedback via practice surveys and
involvement in service development• Initiatives for patients to manage demand for
services• Consultations at 10-minute intervals
Patient Services Guarantee
• Access to wide range of services in primary care
• Most practices deliver the full range of additional services
• Extending patient choice– Choice of service provider– Choice of additional service provider (when
practice opts out)– Availability of parallel additional services– Choice of advanced service provider
Working in partnership
• Development of management and education programmes for self-care
• Development and support of Expert Patient initiatives
• Supporting non-GP chronic disease management schemes
• Promotion of Doctor Patient Partnership and health charity initiatives
• Promoting education of young people via the National Curriculum`– Possible major opportunity
Implementation
• NHS contract between the local PCO and the practice– Services provided– Level of quality– Infrastructure and support– Financial resources
• Teamwork encouraged with GPs and other professionals
Alternative providers
• PCOs can commission or provide services– Maximum flexibility to commission
enhanced services, including from the private sector
– Essential primary care may also be provided by GP walk-in centres
– From 2006, what are now specialist services can be provided in primary care
Contract review
• Formal review process– Annual return from the practice– Annual review, typically involving a visit
• Evidence-based review in the medium to long term
First steps
• Doctors’ and Dentists’ Review Body asked to endorse the agreement
• Primary legislation introduced
• Contract implemented in a phased way
• Substantial implementation will occur in 2003/04
• Problem with underfunding
Identifying opportunities in the new contract
Concepts
• In the future the career of medicine will involve collecting competencies– Core– Specific
• Developing relative competencies in headache management– Specialist GP (GPSI)– General GP– Nurses– Pharmacists
Service delivery
Initiatives relevant for headache management - 1
• Management of chronic disease in discussion with the patient (essential service)– Communicating with patients a key organisational
domain– Improving public education– Patient input via practice surveys and
involvement in service development– Bringing general GPs, nurses and others up to
standards
• MIPCA guidelines for migraine and CDH emphasise patient-doctor partnership
Initiatives relevant for headache management - 2
• Enhanced services encourage development of more specialist services– GPSI schemes– Primary-secondary care interface– Clinical leadership schemes
• MIPCA guidelines for GPSI in headache and setting up headache clinics in primary care
Initiatives relevant for headache management - 3
• Education and training a key organisational domain– Learning and personal development
supported through protected time– Education and mentoring a key part of
clinical leadership– Improving public education and promoting
education of young people in schools
• Opportunity for development of MIPCA diploma for headache education
Initiatives relevant for headache management - 4
• Development and support of ‘expert patient’ schemes– Promotion of health charity initiatives
• MAA is funded to provide a specialist patient programme for headache
Initiatives relevant for headache management - 5
• Supporting practice staff– Quality framework applies to practice team rather than to
GP– Nurses supported to take on advanced and specialised
roles• First contact care, chronic disease management and preventive
services– Pharmacist and allied professionals included in practice
team– Teamwork encouraged between GPs and other
professionals• MIPCA guidelines for nurses and pharmacists, and
encouragement of the primary care headache team• Lobby for NICE headache guidelines via Headache
UK and/or SIGN
Pharmacist
Community nurse
Optician
Dentist
Complementary practitioner
Patient
Primary care physician
Practice nurse
Physician with expertise in headache:
GP; PCT; specialist
Ancillarystaff
Primary care Specialist care
Associate team Core team
Copyright MIPCA 2002, all rights reserved
Initiatives relevant for headache interventions
• Headache is not one of the clinical domains• Lobby to include headache• MIPCA guidelines comply with clinical and
organisational indicators– Based on best available evidence– Assessment based on diagnosis and initial and
ongoing management– Patient communication important– Obtain NICE endorsement to raise status of
headache
Production of educational packages
• Education and training of professionals and the public to be supported
• MIPCA plans to develop a modular education programme for headache– GPSIs– GPs– Nurses and other professionals
• Courses for educators of professionals and the public (training the trainer)?– Specialist patients
Outputs for governance
• Audits– Clinical indicators– Patient surveys– Evaluating professional development
• Education and training• Link with RCP to demonstrate that specialist
standards are being met
– Appraisal
Design of audits
Quality indicators for clinical domains
• Based on best available evidence• Data needs to be useful for patient
care, and not just for audits• Indicators
– Medical records– Diagnosis– Initial management– Ongoing management
• Patient surveys
Epilepsy
• Records: – Register of patients receiving drug treatment
• Ongoing management:– Seizure frequency over past 15 months for
patients (≥ 16 y) on drug treatment– Record of medication review over past 15 months
for patients (≥ 16 y) on drug treatment– Proportion of patients (≥ 16 y) on drug treatment
convulsion free for last 12 months
Asthma
• Records: – Register of patients receiving drug treatment for
asthma over previous 12 months• Initial management:
– Proportion of patients (≥ 8 y) with diagnosis confirmed by specific testing
• Ongoing management:– Smoking status (14-19 y and ≥ 20 y)– Smoking cessation advice given– Asthma advice given over past 15 months– Record of influenza immunisation in preceding
Autumn / Winter
Possible audits for headache
• Clinical indicators
• Education and training
• Effects on practice
• Management of audits
Clinical indicators
Records
• Register of patients with headache
• Register of patients receiving drug treatment for headache
Clinical indicators
Diagnosis / initial management• Proportion of patients diagnosed with different
headache subtypes (migraine, TTH, CDH, cluster, sinister) over the past 12 months
• Record of medication history• Record of co-morbidities• Patients self-referred / referred by another
professional (e.g. pharmacist)• Patients given management education / advice• Patients sent for procedures / referral• Patients given a headache diary or other
questionnaires to complete• Patients treated with prescribed drugs: acute and
prophylactic
Clinical indicators
Ongoing management• Register of follow-up appointments• Record of headache status• Medication compliance review• Completion of headache diaries and other
questionnaires• Record of patients whose treatment (acute
and prophylactic) was changed• Success of initial and follow-up medications
Education and training
• Record of personal learning plans
• Annual appraisals of primary care team (GPs, nurses, others)
• Review of patient surveys
Effects on practice
• Record of practice team arrangements
• Record of time and resources spent dealing with headache
• Number of patients diagnosed
• Number of patients on acute and preventive treatments
Audit toolbox
• Record forms– Headache history questionnaires– Patient checklists– Headache diaries– Impact and other questionnaires
• Audits conducted by nurses and other practice staff