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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
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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
5
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
7
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
8
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
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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.