Wednesday, May 26, 2004
Jonathan Coulter – Director of Finance (North Bradford PCT)
Spending the day with Jonathan provided me with some very good insight as to how health services are commissioned, provided and financed.
Each PCT receives an annual allotment of money from the Department of Health determined by the number of patients and the characteristics of these patients. Each PCT must be accountable for remaining within their allotted budget, and in achieving the clinical targets set out by the NHS. As long as the PCT is managing their patients and money appropriately, they have the freedom to use their budget as they see fit. Should a PCT overspend their budget, the Strategic Health Authority will assume tight control of the PCT’s spending to bring them back onto track quickly.
The PCT uses their budget to purchase health services, employ various clinicians who work with patients, and employ PCT staff.
Health services are funded in a variety of ways:
- Hospital and Specialist services are purchased on a contract basis. The number of needed services (ex: 700 hip replacements) are estimated at the start of each budget year and make up part of the service contract. If, at the end of the year, more services than what were estimated for are used, the difference is paid to the provider by the PCT. Each PCT sets requirements for the service provider to ensure that high quality care is being given. These requirements include things such as patient waiting times to access the services, and quality of services. If a particular hospital is not meeting these requirements, the PCT will contract with another provider, including those in the private sector.
- GP services are also paid for on a contract basis. GP Surgeries are allotted a yearly budget based on the number of registered patients they serve and the ethnicity and deprivation of these patients. Each Surgery decides how to use this money to best serve their patients, and meet the NHS and PCT targets for healthcare. Many Surgeries employ nurses and other healthcare professionals to provide a variety of services for their patients. Budgets must also include drug costs for all medications prescribed by the GPs. Should the Surgery operate under budget for the year, which is one of the targets in the North Bradford PCT’s incentive scheme, they will earn a monetary “bonus”. This, and other financial incentives earned are usually recycled back into the practice and used to further improve patient outcomes. This form of payment promotes quality of care, not quantity of care. The Commission for Health Improvement website outlines the entire incentive scheme.
- Pharmacy Services. The way pharmacy services will be commissioned is changing with the introduction of the new Pharmacy Contract. As the contract is still under development, I am not aware of many of the details. However, I do know that they are looking at an alternative way to reimburse how pharmacies are paid. Currently, pharmacies are paid the “set” cost of the drugs and a small dispensing fee, with the majority of profit coming from savings made on drug purchase price negotiations, and front store items. The idea is to be paid in a similar way to the GPs – based on quality of the service, not the quantity – with the elimination of the dispensing fee. Pharmacies will receive a fee based mainly on the number and characteristics of the patient population they serve.
The PCT also employs clinical pharmacists who spend time in the GP Surgeries performing medication reviews, patient education, and assisting GPs in meeting their prescribing targets. The PCT is also looking to employ pharmacy registrars who will work in community pharmacies helping the existing pharmacist develop a more clinical practice, as well as freeing them up to spend time in GP practices.
Nursing Services for home care patients and public health are provided by nurses employed by the PCTs. Practice nurses, located in GP Surgeries are employed by each individual Surgery.
Interesting Notes/Key Thoughts
One comment that stuck in my mind: “Public health care can be successfully and efficiently provided by the private sector. As long as the patients do not pay for it, it is still public”. Perhaps this is an avenue that warrants further consideration?…
Friday, May 21, 2004
One theme that has consistently come up throughout my visit is the necessity of continually performing PDSA cycles. Plan-Do-Study-Act cycles are key in ensuring that change is successful.
The following information is adapted from a document compiled by Emma MacLellan-Smith, North Bradford NPDT Access Lead:
Making improvements in anything, healthcare services included, requires change, which many people regard as threatening or overwhelming. The PDSA cycle is a way to break down change into manageable chunks, and test each small part to ensure things are improving and that no effort is being wasted.
PDSA is a model that can be used to test ideas for improvement quickly and easily, based on existing ideas, research, feedback, theory, review, audit, etc. The PDSA uses simple measurements to monitor the effect of changes over time, and encourages starting with small changes. Small changes grow into larger improvements through quick successive cycles of change.
The PDSA cycle has been used for decades as an effective tool for improvement. The method is well established, validated and is particularly suited to small, dynamic organizations such as general physician practices. It provides an extremely practical, common sense approach that is easy to perform and understand.
Step 1 – PLAN
Identify what change(s) you think will create improvement and then plan how to test the change. What is your objective for introducing the change? It is important to establish the scope of the change to be introduced, how you are going to collect information about the differences that result, and how you will determine whether the change made has worked or not. The change should bring about differences which are measurable in isolation. A major change can be broken down into smaller more manageable “chunks”.
Once the actual change to be introduced has been agreed upon, the following questions should be asked:
- What would we expect to see as a result of this change?
- What data do we need to collect to determine the outcome of the change?
- How will we know if the change has worked or not?
- Who, what, where, when?
Step 2 – DO
Put the plan into practice. This stage involves carrying out the plans agreed to in Step 1, and should be kept as short as possible. Change(s) can be tested by collecting the appropriate data, although there may be changes that require being measured over longer periods. Record any unexpected events, problems and other observations. Begin analyzing the data in this step.
Step 3 – STUDY
Review and reflect. Complete the analysis of the data. Ask whether there has there been an improvement. Did your expectations match the reality of what happened, and if not, what could be done differently?
Step 4 – ACT
After deciding what has worked and what has not, make any further changes or amendments, and collect data again. Carry out an amended version of what happened during Step 2 and measure any differences that have occurred as a result of the implemented change(s).
PDSA cycles reduce the difficulties in getting changes started. Testing small changes sequentially means that design problems can be detected and amended earlier rather than later, saving huge amounts of effort being put into massive change which may have to eventually be altered.
Hints and Tips
- Keep it simple.
- Keep it small and manageable – massive projects can be broken down into a number of small, quick PDSA cycles.
- Cycles should happen quickly – think in terms of a week not a month.
- There is no wrong answer, if you find something works, use it.
- Re-use and adapt other people’s ideas if you think they may be useful.
The NPDT Website is a useful resource on PDSA Cycles
Thursday, May 20, 2004
Mike Rymer – Pharmaceutical Advisor (Eastern Hull PCT)
The Eastern Hull PCT had begun piloting the Minor Ailment project with pharmacies within their PCT. Minor Ailments is exactly that – rather than patients going to their GP for relatively minor problems, they consult their pharmacist for advice and/or a “prescription” for an appropriate product. This decreases the number of inappropriate GP visits, improving access for those patients who do require a GP assessment.
There are several criteria that the PCT look at when choosing those pharmacies who can participate. They must have, or be in the process of creating, a private consultation area, have a highly qualified technician help available to free up the pharmacist for consultation when necessary, and they must employ a pharmacist who works in the pharmacy on a regular basis so as to be able to develop relationships with the patients. Pharmacists must also complete, or be in the process of completing, an accreditation program as determined by the PCT. Although pharmacies can refuse to participate in the Minor Ailment project, they will not be considered for other PCT-funded pharmacy programs, which the upcoming Pharmacy Contract is full of. Currently, 18 of the 24 pharmacies located within the PCT are participating.
So how does the Minor Ailment scheme work?
The PCT is trying to develop a method for having patients register with the pharmacy of their choice, therefore fostering a relationship between the patient and pharmacist(s). This obviously proves challenging as many patients are used to the freedom of polypharmacy. However, each GP practice has been asked to promote the idea to their patients, and several pharmacies have taken it upon themselves to “recruit” and register patients. Although a patient is registered with a single pharmacy, they are able to use the services of another pharmacy, particularly if their pharmacy has limited hours.
When a patient presents to the pharmacy with a minor problem, the pharmacist performs an assessment, provides advice, and may or may not recommend a product. If the pharmacist feels the problem warrants the attention of a physician, a referral is made to the patient’s GP, and the patient receives a priority appointment.
If the pharmacist determines that a product is needed, they dispense it in the same manner as if it had been a prescription from the GP. Those patients who receive coverage for their prescriptions will receive coverage for the product(s) recommended by the pharmacist. This hopefully will eliminate those needless visits to the GP by patients who previously required a physician’s prescription in order to receive coverage. Patients without drug coverage will pay the usual £6.40 (or less if the over-the-counter product is cheaper). The pharmacist documents the details of the visit, including their assessment, advice/product given, and planned follow-up if required, and send it to the patient’s GP.
Much of what has been outlined is being performed by pharmacists already. However, the debate has always remained with regard to payment for these cognitive services, especially if a product is not recommended. Pharmacies involved in the Minor Ailment project receive an overall fee for providing this service, as well as their customary dispensing fee (the equivalent of ~$2.00 Canadian). By doing this, a product doesn’t have to be dispensed to receive the majority of the payment. The fee is determined for each pharmacy individually by the PCT, and is based primarily on how many patients the pharmacy services.
As with all pilot projects, there are still several concerns that need to be addressed:
- what is the most efficient and convenient way to get patients registered to a pharmacy?
- is there a way to ensure that the advice given by the pharmacists will not conflict with the advice given by GPs?
- how are patients attitudes and behaviours changed to get them into the habit of going to the pharmacy first for minor issues?
Although only in the pilot stage right now, the Minor Ailment scheme is likely to be rolled out nationally in the near future, and provides an ideal opportunity for pharmacists to promote themselves as vital members of the primary healthcare team.
Interesting Notes/Key Thoughts
“If you don’t take change by the hand, it will grab you by the throat”
Wednesday, May 19, 2004
Emma MacLellan-Smith – NPDT Regional Access Lead (North Bradford NPDT)
I have had several opportunities in the past two weeks to discuss the concept of Advanced Access. Advanced Access is a way to improve patient access in general practice (primary care) based on ensuring a balance between demand for services and the capacity of the practice to deliver them. Advanced Access helps practices to understand the size and nature of their patients’ needs in order to develop services to effectively meet these needs. Benefits of Advanced Access include:
- patients that are happier
- patient flow is smoother
- practice staff are less stressed
- clinicians are more in control of their workload
Briefly, I will outline the four principles of Advanced Access.
- Understanding Demand – collect data regarding how many people wish to be seen at the practice, and when they wish to be seen.
- Shaping the Handling of Demand – there are many alternatives to face-to-face consultations which can be offered to patients: telephone follow-ups, email, self-help, etc.
- Matching Capacity to Demand – match the capacity of the practice to the predicted demand. This includes looking at the skill mix of staff within the practice.
- Contingency Plans – plan development for both predictable (holidays) and unpredictable (flu epidemics, staff illness, etc.) events to ensure that access is not compromised.
- Communication – between staff and especially patients about the introduction of the new system is essential.
A more complete overview of Advanced Access, including case study examples, can be found here (click on Advanced Access in Primary Care – Booklet).
Access to primary care services has been a focus of the NPDT for the past two years, and many successes have been realized. The North Bradford NPDT Centre has recently reported that 93% of their patients are able to see their GP within 48 hours (working days).
Interesting Notes/Key Thoughts
Advanced Access is something that can be performed and achieved relatively easily by physician practices in Saskatchewan, with benefits being evident within the first few months. Not only will patient care be enhanced, both patient and practice staff will experience a higher level of satisfaction.
Tuesday, May 18, 2004
Jane Robinson – Project Manager (Pursuing Perfection in Bradford – Falls Project)
Pursuing Perfection (PP) is an international initiative to radically improve the quality of healthcare. The concept began in the United States in 2001, and is currently being piloted in several sites throughout the UK with the support of the NHS Modernisation Agency.
The Boston-based Institute for Healthcare Improvement began the program in response to two seminal reports on American healthcare – one highlighting the number of deaths from medical mistakes, the other suggesting the solution lay in centring the system on patients’ individual needs and preferences while encouraging teamwork. In the UK, the program is working to “raise the bar” and move towards standards of care never attained before. A “perfect” health and social care community is defined as a place where there are*:
- no avoidable deaths or disease
- no harm
- no unnecessary pain
- no waste
- no delays
- no feelings of helplessness
- no inequality
*NHS Modernisation Agency – An Introduction to Pursuing Perfection
The Bradford Community of PP has eight areas that they are currently focusing on: Cardiology, Endoscopy, Stroke Services, Skin Cancer Services, Emergency Services, Haematuria, Medicine Management, and Falls. I had the opportunity to discuss the Falls project with Jane. Fractures from falls are becoming increasingly common, especially in the elderly. Fractures have a negative impact on patient morbidity as well as create a significant economic burden to the healthcare system. Because of this, PP has chosen falls to be one of their priorities. Rather than outline the whole program, I have provided a link which better explains it.
Interesting Notes/Key Thoughts
“Why pursue perfection? Because that way you will achieve as much as you possibly can. If you aim for the top and get halfway there, you’ve got something which will still make an enormous difference to patients. If you only aim halfway and don’t get there, patients are going to loose out.”
Dennis Molloy, Patient, Chair of Lambeth Breathe Easy Group
Monday, May 17, 2004
Leslie Hill – Deputy Chief Executive (North Bradford PCT)
I had the opportunity to sit in on a meeting with the North Bradford PCT’s Deputy Chief Executive, Finance Manager, and non-Executive board members reviewing the PCT’s Local Delivery Plan (LDP). The LDP is much like an action plan which outlines the PCT’s vision, the key healthcare areas it will focus on, and how they plan to address these areas in the coming year. The NHS outlines several national goals that each PCT must act on, however individual PCTs may also incorporate their own areas of focus. The North Bradford PCT had 30 areas of healthcare that they decided to focus on, ranging from cancer to patient access of the healthcare system. This meeting was in essence a “reporting” to the Board on how the PCT was performing in each of the 30 areas.
North Bradford has been very aggressive in its approach to the enhancement of healthcare, and each of these 30 areas have experienced some amount of progress over the past year. I was most impressed with the positive attitude that all members of the PCT exhibited towards their LDP. Many targets had been achieved, and those that had not, all had strategies in place for how they would be. Although not every approach, or intervention applied is successful, failures are never viewed in a negative fashion. Rather, they are regarded as an opportunity for learning, development, and innovation. The amount of support and dedication to the achievement of the the LDP from all levels within the PCT is unmistakable, and no doubt a reason for its success.
Interesting Notes/Key Thoughts
- The importance of planning was evident, from the vision to the strategies for achieving objectives and targets.
- Risk Management occurs when objectives have not been met.
Dr. Ian Rutter – Chief Executive (North Bradford PCT)
An informal sit-down discussion with the Chief Executive provided valuable insight on the attitudes of the PCT executive and their approach to managing healthcare. As a GP who is still in practice, Ian is able to draw from personal experiences when leading the PCT.
Interesting Notes/Key Thoughts
- Successful changes do not occur all at once. Small continual changes have a bigger influence over the whole picture.
- To implement timely change, it is important to work with the “early adopters” rather than wait for everyone to come on board.
- Committees are an inefficient way to make decisions regarding change. The North Bradford PCT empowers individuals to make decisions, rather than relying on committee decisions. Ideas are “bounced off” several team members in a parallel position before they are initiated.
Friday, May 14, 2004
Julie Winterbottom – Assistant Director of Commissioning (North Bradford PCT)
The North Bradford PCT is one of the most forward-thinking PCTs in the country. They are constantly looking for ways to enhance primary care, and embrace the opportunity to do so by “thinking outside the box”. Today proved to be very informative as I received a comprehensive overview as to how the PCT operates and supports physician services. This particular PCT has 12 physician practices, with 60 general practitioners (GP), and services approximately 130,000 patients. Each GP cares for an average of 2000 patients.
Each GP works out of a Surgery (what we consider clinics in Saskatchewan), whether it is as a single practitioner or as part of a multiple GP practice. Patients are rostered to a specific GP or GP-Surgery where they are expected to access all their primary care services. A GP-Surgery usually employs practice nurses and/or nurse practitioners, and may employ the services of other healthcare professionals (pharmacists, therapists, etc.) that they feel will benefit their patients and their practice.
The North Bradford PCT allots a portion of money to each Surgery based on the number of patients it services and the characteristics of these patients (deprivation, ethnicity). This forces all budgeting and service provision decisions to the individual Surgery level, as they must decide how to use the money in order to better improve patient care and attain NHS targets. The NHS is constantly developing national targets concerning patient care that GPs are expected to achieve (eg: GP appointments within 48 hours of request). As GPs achieve each target they receive monetary incentives to be used as they wish, although it is usually re-invested into the practice. The PCT provides continual development, promotion, education and support to each Surgery and works closely with each practice to ensure that NHS and PCT targets are being reached.
The goal of primary care in North Bradford is to keep the patients from entering secondary (hospital) or tertiary (specialists/surgery) care. One way the North Bradford PCT works to achieve this is through the development of GP’s with Special Interests (GPwSI). These are GPs within the PCT who have a special interest and become accredited in a specialty area (from dermatology to urology). Patients within the PCT are referred to these GPwSIs initially, rather than jumping straight to the specialist in the hospitals. Most patients can be successfully managed by the GPwSIs and the more complex patients can be referred for further specialized care if required. This method has not only decreased patient waiting times to see a specialist, but has proven to be economically beneficial as well.
The PCT fully supports all GPs who show an interest in becoming a GPwSI both financially and through the provision of locum coverage during training. Accreditation is achieved through distance diplomas. Practical training is done by local PCT specialists in order to develop good working relationships between the physician groups and to allow for a feeling of ownership by the specialists. Complete accreditation can take anywhere from four months to one year, depending on the GP’s previous education and experience. Practices with GPwSI receive additional funding from the PCT as they are expected to still cover their initial patient population, as well as take on the additional referral patients.
As previously mentioned, most Surgeries employ either a practice nurse(s) and/or a nurse practitioner(s). Nurses have scheduled appointments where they see patients who do not need to be seen by a physician at every follow-up visit. Although they often perform many “technical” duties (blood pressure checks, phlebotomies, etc.), the shift has been to having the nurses manage those patients with chronic diseases. Technical duties in many Surgeries have now been delegated down to the reception staff, as many of them have received training in blood pressure measuring, and phlebotomies. This not only frees up the GPs and nurses to deal with more complex patients, but has greatly reduced patient waiting times for appointments as well.
Interesting Notes/Key Thoughts
- The majority of top executives in the North Bradford PCT are healthcare professionals who are currently in practice. This practical knowledge and experience is invaluable in guiding decision making.
- There is accountability at all levels of the healthcare system. Each GP is accountable to the PCT to prove that optimal patient care is being offered, and the PCT is accountable to the Department of Health in ensuring that national (NHS) objectives are being met.
- North Bradford PCT has realized that successful patient care is not obtained by dumping money into secondary care. By investing in primary care, and therefore keeping patients out of the secondary care, better economical and patient outcomes are achieved.
Many of these concepts seem foreign compared to how healthcare is delivered in Saskatchewan. Although not every aspect of the English system is suitable to Saskatchewan, I believe there are many theories and concepts that we can embrace and adapt to further improve how we deliver primary healthcare.
Thursday, May 13, 2004
Simon Grant – Pharmaceutical Advisor (North Bradford and Bradford City PCT)
My first “official” day was spent in a variety of settings, each of which enhanced the respect I have quickly developed for the health system over here. Our first meeting was with a hospital pharmacist who was in the process of designing and implementing a pilot project concerning seamless care between secondary (hospital) and primary care. By determining how often discharge medication and follow-up orders are carried out once the patient leaves secondary care, the hope is that any lapses in seamless care can be identified and corrected.
We spent the afternoon in a meeting with the Bradford City PCT’s Diabetes Planning Group, which provides support to 42 satellite diabetes clinics. The group was focused on achieving their goal of having all patients with diabetes accounted for on a diabetes “register” by September. The purpose of the “register” is to provide a convenient way for physicians to ensure that their patients are receiving optimal care and follow-up, and that disease targets, set out by the NHS and the PCT, are being achieved. I was so impressed with the focus of the group and the determination they exhibited in achieving the “registration” earlier than September. I believe much of the success of the group can be attributed to the fact that it encompasses members from a variety of health professions, many of whom are currently involved in active practice.
Notes of Interest/Key Thoughts
Unlike Saskatchewan, pharmacists in England are not permitted to automatically dispense the generic equivalent of a drug. The generic has to be specified by the physician, otherwise the brand name medication must be dispensed. There is currently a push to encourage physicians to prescribe generics as a cost savings measure to the PCTs. Patients pay a flat fee for each prescription regardless of its cost, although some patients receive partial or total government medication coverage (based on deprivation, similar to the system we have in Saskatchewan).
Wednesday, May 12, 2004
In order to give you a glimpse of how the health system is set up in England, I have taken the diagram below from the National Health Services (NHS) website. What the diagram fails to illustrate is the role that the National Primary Care Development Team (NPDT) plays within the health system. The NPDT is part of the NHS Modernisation Agency. The NPDT was initially set up, in February 2000, to operate the National Primary Care Collaborative (NPCC). The aim of the NPCC was to use the collaborative methodology as a means for providing primary care with the organizational and individual skills needed to create lasting improvement in the delivery of services; in essence to provide a “one-stop-shop” for primary care.
There are currently eleven NPDT centres nationwide, which continue to provide system support to the individual Primary Care Trusts (PCT) in their enhancements of primary care. Aside from being a point of contact, information and training, NPDT teams operate as a mini-collaborative for PCTs locally, and are supported by a national team.
PCTs are similar to Saskatchewan’s Regional Health Authorities. Each individual PCT provides health services to its population through the employment of a variety of health professionals and providing support to physician practices. PCTs determine how funding is allotted throughout the region, and although they all have the same mandate from the NHS, develop further unique programs and initiatives.
I am stationed with the North Bradford NPDT which supports 23 individual PCTs, and is housed in the same office as the North Bradford PCT. My visits are generally with the local North Bradford NPDT and PCT team, although I do have the opportunity to visit neighbouring PCTs.
Tuesday, May 11, 2004
I arrived in England on Monday, after a much delayed and re-routed trip…although my luggage thankfully arrived at the same place and time that I did.
I’ve only spent two days with the team at the North Bradford Primary Care Trust and already have seen such innovation and forward thinking both of which are obviously a huge part of their successful primary care system. Everyone is so excited about health care – what they have accomplished and what they still have to accomplish. I am truly indebted to everyone for their welcoming and accommodating attitudes!
What I have been doing so far is coming back every night and documenting what I’ve seen/learned that day, what “take home message” I’ve gotten out of that paticular day, and what questions I still have. My goal is to compile each day’s notes into a weekly report and post it at the end of each week.
If anyone has comments or anything they would like me to research while I am over here, please do not hesitate to email me.