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