organisation

							  Organisation of Primary
    Healthcare Systems:
UK Experience, European and
 International Perspectives
            Dr. Simon de Lusignan
            Primary Care Informatics
          Chair EFMI PCI Working Group
     GP Woodbridge Hill Surgery Guildford
      Division of Community Health Sciences
        St. George's - University of London
   Overview
• What is primary care
   – Definition of primary care…
   – Consultation is the “commodity” that primary care delivers
   – Informatics is an enabler of quality
• Primary healthcare in UK
   – Division into Commissioner + Provider
   – National frameworks + standards (e.g. NSF, NICE, Health Commission)
• UK GP as provider
   – Quality based-contract - Practice Based Commissioning
• Information system to support primary care
   – Components:
   1) Unique identifier – 2) Coding system(s) – 3) Level of interoperability
   – Compare:
       • England: Integrated National programme for IT : “Connecting for Health”
       • “European” approach: Improving interoperability between systems
       • Scotland: Linkage of records using CHI (Community Health Index) number
• Conclusions
   – Explicit quality standards, measured using IT are a useful component of a
     modern primary healthcare system
Introduction

        What is primary care?
   What is primary care informatics?
What is primary care?
• Based on first contact:
   – The first-contact health service for a
     patient who is sick or injured is staffed
     by trained primary care professionals.
     (Fry)
• Any problem, any time:
   – primary care as the specialty that sees
     any patient(s), with any combination of
     problems, any time
• Comprehensive coordinating
   – first-contact care, longitudinality,
     comprehensive services, and
     coordination (Starfield)
  Clinical consultation
• The core of healthcare delivery
• Usually one-to-one
   – Biospyschosocial model of disease
     (Engel)
   – Problems from physical, psychological
     perspectives
   – Therapeutic effect of the consultation
     (Balint)
• Patient-centred
   – Exploration of patients ideas /
     concerns / expectations (Pendleton)
• Changes
   – Increased management of chronic
     disease
   – Prevention and screening
   – More consultations with healthcare
     assistants and nurses
 Patient-centred care
• Choice + patient
  autonomy
   – Top down - e.g. Choose
     and book – referral
   – Expert patient groups
   – Bottom-up – change in
     social attitude - e.g.
     Counselling
   – Responsibility for own
     health e.g. lifestyle
• More healthcare in the
  community
   – Patients self monitoring e.g.
     Anticoagulants, telecare
   – “Tier-2” services
   – Intermediate care
  Patient-centred care (2)
• Practice based
  commissioning
   – Practices / groups of
     practices taking responsibility
     for services
   – Incentive to provide locally
     based better value for money
     services
• Enabled by informatics..
   – Searchable medical records –
     allow quality to measured
   – NPfIT will enable healthcare
     records to be patient centred
     not fragmented between
     institutions
UK Primary Healthcare
Primary care in UK (in England)
• State funded system…
• Division into commissioners + providers of care
• Commissioners – decide what care is to be provided
   – Must implement national guidance
       • NSF (National Service Frameworks)
       • NICE (National Institute for Clinical Effectiveness) guidance
   – Must meet Access Targets
       •   4 hours casualty
       •   Same day and 48 hour access to a GP
       •   2 weeks suspected cancer
       •   13 weeks OPD,
       •   6 months to surgery
   – Inspection:
       • Healthcare Commission
   – Many health communities have large deficits….
Primary care (in Scotland)
• Consensus style management
• No internal market
• Health boards
  – Consensus management of primary
    + secondary care
  – Community health partnerships with
    social care
GP as provider of services

      Quality based contract…
 Quality based contract…
• Points for achieving quality in:
   – Heart disease, Hypertension, Diabetes etc.
   – Financially incentivised
   – “Score” and financial remuneration based on
     collection of routine computer data
   – Limited list of recommended computer codes…
   – All practice scores are in the public domain
Practice based commissioning
• Groups of practices coming together to commission and
  provide services
   – Competition a driver to collaborate
   – Will need to manage budgets to achieve savings
   – Clinician led groupings
• Recommended approx 50K to 100K registered patients
   – Larger groups needed to provide Tier 2 services
• Scope to keep and reinvest savings…
• Can provide services traditionally delivered in hospital
  setting
• Contestability / competition is being allowed in primary
  care
   – E.g. Allied Health
Information systems to
support primary care…
       England – Integration
      Europe – Interoperability
        Scotland - Linkage
Primary care information systems:
• Problem: Fragmented data across health system
 – Primary care clinician needs:
  • Overview of patient’s medical history
  • Practice safely + efficiently
  • Achieve quality
• Different strategies exist to address these needs
 – Integration
  • Systems are integrated – with cross-platform functionality
    – e.g. England – Choose-and-Book
 – Interoperability
  • Systems exchange information
 – Linkage
  • A common identifier allows data to be linked
    – e.g. Use of CHI number in Scotland
Promoting system-wide working
1)       Unique identifier
     •     England NHS number
     •     Europe – many different systems…
     •     Scotland – CHI number
2) Coding system(s)
     –     England – Migration to SNOMED CT
     –     Europe – Usually ICPC in primary care + ICD
           in hospitals
     –     Scotland – Read and migration to SNOMED
3) Level of interoperability
     –     England – Integration of systems – via the
           “spine”
     –     Europe – widespread use of data exchange
           protocols
     –     Scotland – linking data using CHI number
Integration
•   Consolidated system which updates all the
  relevant parts each time data is entered
•  NHS Choose and book project used as an
  example…
    –    Components:
        1. Authenticate GP – smart card + password
        2. GP Clinical system (Mine is EMIS LV – most used in UK)
        3. N3 (NHS Intranet) broadband links to surgeries
        4. National spine – which checks each person for correct
           demographic details
        5. Choose-and-book application
             –   Link to its call centre
        6. PAS (Patient Administration System) in hospital
  Integration – NHS Choose and book
                    2. Spine
1. GP System        2. Spine          3.   Choose and Book
                                           Application
                    2. Spine

                    2. Spine          4. Hospital PAS
                                        4. Hospital PAS
                    2. Spine              4. Hospital PAS
                                            4. Hospital PAS
                    2. Spine

                    2. Spine          5. Patient call centre

                    2. Spine

                    2. Spine          6. SUS – Secondary data


       Link via NHSnet NHS Intranet
Integration – NHS Choose and book
Blue NHS icon indicates connected,
Bottom left demographic details not on spine…
Integration – NHS Choose and book
Connecting to Choose and book application (<1sec)
Selecting a service
Booking the appointment
Scotland: Linking data –
   CHI number - Community Health Index
• This is a combination of
 – Date of birth
 – Gender indicator
 – A number
  • As up to 200 people are born on one day in Scotland
 – A check digit
• Originally a unique identifier in Tayside – later
 adopted across Scotland
• Examples of where it is used to link data
 Types of health and community data linked
                   Opticians
      Lab
                                   PAMS
      Data
    Lab              GP              Screening
    Data

  Pharmacy
                    GPHospital
                                   Opticians
                                   Hospital
  Investigations       SMR


                   Eye Van          PAMS
         Eye van
Investigations
                       Pharmacy   Screening
The DARTS / MEMO
   Collaboration
Practical uses
– DARTS diabetic study…
     100       Mortality Post
      90       Myocardial Infarction
                      No Diabetes       Diabetes
      80
      70
      60
      50
      40
           0   1        2          3          4
                   Years Post MI
                             Diabet Med 2002; 19, 448-55
Discussion
  Primary care
• Unique speciality with its own
  informatics subspecialty
• Able to meet challenges to raise quality
   – Screening + prevention
   – Chronic disease management
• Effective in different systems:
   – commissioner-provider split
   – consensus managed systems
• Incentives appear to lead to quality
  improvement
• Informatics is an important enabler of
  quality
• Consider:
   – Unique ID, Coding systems, Interoperability
• Simple low cost technologies may be as
  effective…
Thanks for listening…
Simon de Lusignan

St. George’s University of London

Tel:       ++44(0)20 825 5661
Email:     slusigna@sgul.ac.uk