Regulation in Primary Care

-Impact in N Ireland

Dr Sloan Harper

Director of Integrated Care

Health & Social Care Board

Primary care providers NI

GP Practices 351

GP Out of Hours providers 5

Community Pharmacies 530

Dental practices 380

Optometry practices 281

How do we improve primary care

services?

• Targets & performance?

• Choice & competition?

• Inspection & regulation?

General Medical Services Regulation

The Health and Personal Social Services (General Medical

Services Contracts) Regulations (NI) 2004 and amendments.

• GP Contract – a clinical governance framework

• Practices failing to meet the requirements can be issued a “remedial

notice” requiring improvement within a defined period, followed by a

“breach notice” and termination of contract

General Medical Services Regulation

The Health and Personal Social Services (Primary Medical Services

Performers Lists) Regulations (NI) 2004 and Amendments.

• Individuals can be removed if they have not provided GMS services

in last 24 months, on basis of GMC decisions, convictions for certain

serious crimes.

• Inclusion on the list can be deferred during investigations.

• Regional Performance Panel with professional and lay members

advises HSCB

Benefits and Challenges• Statutory basis provides definitive requirements and

ways to address shortcomings• Clinical underperformance

• Infrastructure

• Workforce development & accreditation

• Processes can be slow, including time for GMC

investigations

• Cultural issues

• Motivation

• Trust

Procedure for handling of concerns about FPS Practitioners

Concerns Raised

Stage 1

Allocated to Case Officer

Stage 2

Regional Professional Panel

Stage 3

Reference Committee

Director of Integrated Care

Director of Integrated Care

through Assistant Directors

GMS, Pharmaceutical,

Dental, Optometry Services

Director of Integrated

Care through Chair of

Panel

HSCB Board through

Reference Committee

All cases managed, recorded,

concluded

Managed, recorded and

reported to Regional

Professional Panel or

referred to RPP

Advice on investigation and

management including

direct referral to Counter

Fraud and Probity Services;

onward referral to

Reference Committee

Adjudication on referral to

disciplinary authorities eg

national regulators, PSNI*,

HPSS Tribunal.

Adjudication on PMPL**

actions for GPs

Accountability Outcomes

* PSNI: Police Service of NI ** PMPL: Primary Medical Performers' List

Quality & Outcomes Framework (QoF) 2013/14

N Ireland England Scotland Wales

GP Practices 351 7,921 995 465

Max points

available

912 900 923 969

Average

points

achieved

896.5 831.4 900.8 928.9

%

Achievement

98.3% 92.4% 97.6% 95.9%

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

105%

1 10 19 28 37 46 55 64 73 82 91 100109118127136145154163172181190199208217226235244253262271280289298307316325334343352

% O

utc

om

es

HSC Board GMS Practices

Hypertension5 (HYP002NI) - The percentage of patients with hypertension in whom the last blood pressure (measured in the previous 9 months) is 150/90 or less

(maximum threshold - 70%)

2009/2010 Practice Outcome

2013/2014 Practice Outcome

Pharmacy

Regulated through:

• Contractual – terms of service set out in

Regulation

• Professional – registration of premises,

superintendent pharmacists and responsible

pharmacists

Medicines

• Human Medicines Regulations (subsumed

Medicines Act)

• Misuse of Drugs Act

Challenges

• Medicines – regulation complexity

• Pharmacists – patient facing role

• Pharmacy support staff – regulation

• Contractual – patient registration; pharmacist

lists

Support for Good Medical Practice…

Dental Regulations

Principal

• General Dental

Services Regulations

(1993)

• HPSS Quality

Improvement

Regulations (2003)

• GDC Standards for the

Dental Team (2013)

Supporting

• Disciplinary Regulations

(2014)

• Patient Charge

Regulations (1989)

• Ionising Radiation

Regulations (2000)

Implementation/ Enforcement of Regulations

GDS Regulations

• Post-treatment record checks

• Post-treatment patient

examinations

• Practice declarations

HQI Regulations-

• 15 published dental practice

quality standards.

• Compliance checked by

annual RQIA practice

inspections

GDC Standards

• Ethical responsibility to follow

• Employers, commissioners

and patients may refer.

• Referrals have to pass

through two screening stages

before a full hearing

Dental

Benefits

• Clear rules, fairness

to all

• Clear lines of

accountability

• Public Confidence

• Assurance of Quality

Challenges

• Tension b/n running a

business and

maintaining quality

• Variation in standards

• Stress among

practitioners

• Resources to monitor

contacts

General Ophthalmic Services

HPSS GOS Regulations (NI) 2007• Schedule 1: (Regulation 2) Terms of Service outlines

requirements for premises and equipment, access hours,

and clinical records etc.

• Schedule 2: (Regulation 3) Constitution of Ophthalmic

Committee

These are backed up by HSC (Disciplinary Procedures)

Regulations (NI) 2014 giving HSCB powers to investigate

allegations that a practitioner has failed to comply with Terms of

Service

General Ophthalmic Services (GOS)Approach taken to governance of ophthalmic service provision

Governance

REGULATIONS

QUALITY ASSURANCE

PATIENT FEEDBACK

1. Current regulatory framework - General Ophthalmic Services

Regulations (Northern Ireland) 2007 - Principal Regulations and Terms of

Service applied to all contractors

2. Directorate of Integrated Care – Manual for the investigation and processes

for management of underperformance

Head of Optometry

Clinical Adviser Team

(1 clinical adviser is Governance lead)

DoIC Business Support

(Governance ABSMs)

Benefits and Challenges

• Listing of all

contractors

• Governance

arrangements in

place to ensure

compliance with

Regulations and

drive up quality.

• No powers of

suspension

• Internal audit has

recommended that

HSCB negotiate and

agree a new GOS

contract to better

monitor & action

performance.

How else could we seek to improve clinical

services?

• Collaboration and co-operation

Delivering integration

What are Integrated Care Partnerships?Networks of providers - Working together to deliver the right care, in the right place at the right time.

ICP Areas