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Lessons from the NHS17th November, 2011
National Primary Care Conference
LivingHealth Clinic
Dr Daragh FaheyChief Medical Officer, UnitedHealth UK
It’s easier when you have money!!
Key Messages
• Ensure incentives for all key stakeholders are aligned with objectives
• Support GP to develop mutual dependency between them and government policy
• Recognise impact of destabilising good work to date with unnecessary structural changes– What and how more important than where and whom – Be patient
• Pay for activity, patient experience, outcomes• Evidence based policy making, pilot first with good
evaluation and then incremental change
History (1)
• Introduced in 1948– Significant financial pressures and disorganisation of the hospitals– GPs independent contractors paid on capitation
• 1952: Danckwerts award – Incentives awarded to doctors with intermediate size lists
• encourage them to take on new partners and develop group practices
– Later upsurge of interest in health centres• group practices loan scheme
• 1965 Charter (relevant points)– Better premises and equipment, more support staff, funded by gov– Incentives for skills and experience– Proper pay for work done outside the normal working day
• GPs very dependent on the NHS
History (2)
• Early 80s – greater move out of hospital (CDM)
– Increased access to sophisticated investigations
• 1989: Large scale reforms proposed:
– Health insurance approach reviewed but rejected
• 1990: Internal market, purc/prov split and devolved dec-making
– Health authorities manage their own budgets and buy healthcare
– Fundholding
• Initially practices (> 11,000) could apply for own budgets for staff costs, prescribing, OPD & certain hospital services, largely elective surgery
– 3 types (community, standard and total) by 1995
• Community: to encourage smaller practices
• Total: controlled large sums >30 m. Employed managers
• GPs with pivotal role but semi-detached status still a challenge
• Evidence on success unclear
• Other approach: ‘locality commissioning"
Pros/Cons Fundholding
Pros• Harness enthusiasm of GPs to
develop their practices.
• Shorter waiting times for their patients and reduced unnecessary hospital referrals?,
Cons• Many commissioners and contractors
increased transaction costs.
• Evidence of a two tier access to health care between patients of fundholders and patients of non-fundholders.
• Ended 1999 by labour. – 500 PCGs (catchment circa 100,000) , took over from 4000 HAs, fundholders, and
locality commissioning groups.
Poorly Evaluated
History: 2000s
• PCGs encouraged to become PCTs• 1999: Practice Based Commissioning
– PBCs had indicative budgets – Savings to be invested locally to benefit patients
• Practices incentivised to provide x-rays, tests, OPD consults within own practice or commission from another
• National tariffs: decrease risk "bargain basement" services.
– Widespread welcome• Supposedly no personal financial advantages for doctors.
– National policy: Universal PBC but effects were patchy with GPs slow to get involved.
• Primary care tsar as " a corpse not fit for resuscitation."
History (2): 2000s
• GPs responsible for health promotion, care of acute disease, and long-term care of chronic illness
• Responsibility for OOHs - PCTs. – Breakdown RCGP’s primary care model -continuity of care
• Introduction of PMS contract – Greater flexibility – payment for activities and outcomes– Facilitates salaried GPs
• employed by health authorities
• Private sector - more integral– APMS contract introduced
• Nurse Led Walk-in Centres– Piloted in stations and shopping centre – Minimal impact on GP workload
History (3) (2000s)
• Pharmacists incentivised to expand into CDM– Supervision of repeat prescriptions, smoking cessation etc.
• Move to EBM culture of public accountability – 147 quality targets, 76 clinical, 20% of budget
• Greater focus on community services & and bringing GPs together• Polyclinics
– Combine GP and some elements of hospital care – Health & social services such as benefits support and housing advice
• Smaller GP led health centres– Gov required every PCT to tender for on
• 8 a.m. to 8 p.m. walk in services for registered or unregistered – Conservatives ‘too top down’ and they are now unravelling
Current Situation‘Liberating the NHS’
• Abolition of PCTs & all GPs become commissioners and hold budget (80%)– Shadow (April 2012), Full (April 2013)
• ‘No decision about me without me’
• £20bn efficiency/savings target over next 4 years
• Huge opposition: BMA, College of Nursing, opposition parties, Lib Dems & GPs– Education of GPs as commissioners
– Time for patients vs time as commissioners
– Privatisation of NHS*
– Bureaucracy (transition cost of £1.7bn, CGs increasing from 163-521 )
– Making government less responsible (SOS ‘duty to provide’)
– Choice VS quality and consistent, seamless healthcare
• Very slow to get legislation approved (now at normal committee stage in Lords)
• Unlikely that GPs will be forced to become commissioners– PCT Clusters housing old PCT staff
• New GP contract: replace some old quality and productivity indicators with those focussing on reducing the number of 'avoidable' A&E attendances.
*conservatives had committed to developing a fully privatised NHS with social insurance scheme in 2002.
Still a long way to go…
75% of GPs call for Health Bill to be withdrawn!
Dutch HealthCare System
• From 2006: Dual funded system
– All primary and curative care (i.e. the family doctor service and hospitals and clinics) is financed from private obligatory insurance.
– Long term care for the elderly, the dying, the long term mentally ill etc. covered by social insurance funded from earmarked taxation.
• Private insurance companies must offer core universal insurance package (includes prescription costs)
– Fixed price for all (irrespective of age, healthy or sick).
– Financed into a regulator fund• 50% from payroll taxes paid by employers
• 5% from government
• 45% premiums paid by the insured directly to the insurance company.
• Regulator sees claims - can redistribute the funds its holds on the basis of relative claims made by policy holders.
– Insurers with high payouts receive more from regulator
What has changed?
Old situation• Patients (60%):capitation• Privately insured (40%):
– fee per consultation
• From January 2006• Uniform insurance system• Fee per consultation (€9)• Capitation (€52)• Fees for specific services
Lessons Learned
• Crucial to get incentives right (QOF)– Focus on activities, user experience & outcomes
• Avoid one size fits all – Don’t mandate the solution e.g GP-Led Health Centres
• Develop mutual dependency between gov & GPs• GPs as commissioners can work
– Beware two tiered system (all should participate)– Provide more training as commissioners– Beware sacrificing patient care
• Evidence based policy changes• Form versus function
– Avoid reinventing the wheel– Be patient
Is Restructuring the Answer?
We’ve all got financial challenges!- cooperate & value each other’s contributions
Email: faheydaragh@hotmail.com
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