Divergence in primary care

What can we learn from Scotland and

England?

Kate O’DonnellGeneral Practice & Primary

Care, University of Glasgow.

Population size.

London 7.43 million North West 6.83 million East of England 5.49 million West Midlands 5.33 million Scotland 5.12 million Yorkshire & The Humber 5.04 million South West 5.04 million East Midlands 4.28 million South East Coast 4.19 million South Central 3.92 million Wales 2.97 million North East 2.55 million Northern Ireland 1.74 million

Rurality.

Number of people per hectare by Council area (2001 Census).

Scotland and deprivation.

Directly standardised mortality rates per 1,000 population, 1990/92, by country and deprivation quintile.

Source: PHIS Chasing the Scottish Effect 2001, Glasgow Centre for

Population Health

Long-term unemployment (% of unemployed aged 16-74).

LLTI across the UK.

Northern Ireland 19.5 Wales 19.4 North East 19.4 North West 17.8 Scotland 17.3 Yorkshire & The Humber 16.6 West Midlands 16.0 UK 15.7 East Midlands 15.4 England 15.2 London 15.1 South West 14.0 East 13.3 South East 12.6

% population (age-standardised), 2001 Census.

Scotland and health.

% of people reporting limiting long-term illness by Council area, 2001 Census

Primary care structure.

Single-handed

Small (2 – 3 GPs)

Medium (4 – 5 GPs)

Large (6+

GPs)

Total

England 2504 (29)

2791 (32)

1996 (23)

1466 (16)

8757

Scotland 175 (17)

370 (36)

290 (27)

212 (21)

1047

Wales 105 (21)

170 (33)

158 (31)

75 (14)

508

NI 71 (19)

190 (51)

78 (21)

32 (8)

371

RCGP Information Sheet No 4, May 2005.

GP numbers % increase from 1985 – 2003:

England 10.9.

Scotland 8.7.

Wales 3.4

NI 5.2

Average practice list size (under nGMS Contract):

England 5891.

Scotland 5095.

Wales 5885.

RCGP Information Sheet No 4, May 2005.

The similarities.

Aging population

Long term conditions

Rising demand for care

Recruitment and retention

Skill mix

nGMS contract

Structural re-organisations

GMS contract.

UK-wide contract.

Patients registered with practices not with individual GPs.

Essential & enhanced services.

Opt-out from out-of-hours responsibility.

Greater emphasis on incentivised care.

Quality and Outcomes Framework.

Quality & Outcomes Framework

Total of 1050 points.

Care incentivised across 19 clinical areas, worth 655 points.

Focus on chronic disease.

In 2006/07 – each point worth £124.

Structural GP and practice characteristics in four UK countries

Variable England Wales Scotland Northern Ireland

Number of practices 8542 501 1056 366

Number of whole-time equivalent (WTE) GPs 31523 1816 3782 1078

Average registered population 6401 6171 5249 5361

Average number of GPs per practice 3.7 3.6 3.6 3.0

Registered population per WTE GP 1666 1674 1343 1663

Single-partner practices (%) 23 19 16 19

Practices with six or more GPs (%) 21 16 20 9

*All figures for 2004-05 with the exception of Northern Ireland 2003-4[12]

McLean et al. BMC Health Services Research 2007 7:74   doi:10.1186/1472-6963-7-74

Average percentage achievement by indicator category and country

Category England Scotland Wales Northern Ireland

'Payment quality'

Simple (14 measures) 93.4 93.7 92.7 94.4

Complex (3 measures) 80.4 84.5 75.3 81.6

Outcome (9 measures) 72.3 74.7 72.0 76.3

Treatment (5 measures) 82.4 83.4 79.8 85.4

'Population achievement'

Simple (14 measures) 91.9 92.6 91.6 93.4

Complex (3 measures) 76.4 79.1 71.9 77.7

Outcome (9 measures) 68.2 69.8 67.1 72.2

Treatment (5 measures) 72.6 72.8 68.3 76.4

McLean et al. BMC Health Services Research 2007 7:74   doi:10.1186/1472-6963-7-74

Prevalence rates reported in the Quality and Outcomes Framework in the four UK countries

Prevalence (%) England Scotland Wales Northern Ireland

CHD 3.59 4.61 4.20 4.28

Stroke 1.43 1.80 1.69 1.50

Hypertension 11.32 11.85 12.70 10.60

Diabetes 3.45 3.50 3.90 3.00

Ratio to England

CHD 1 1.28 1.17 1.19

Stroke 1 1.26 1.18 1.05

Hypertension 1 1.05 1.12 0.94

Diabetes 1 1.01 1.13 0.87

McLean et al. BMC Health Services Research 2007 7:74   doi:10.1186/1472-6963-7-74

Governance & incentives.

QOF monitoring appears more rigid in England.

Scotland: QOF verification, but no sanctions.

Exploring how GMS governance is enacted.

Impact of incentivised on practices and on patients.

Suggestion that enhanced services being developed to met local health needs, but may lead to increased monitoring.

The differencesScotland.

Integrated Health Boards.

Managed clinical networks.

NHS 24 front-ending ooh calls.

Traditional ooh delivery in PC.

“Soft” monitoring in QOF.

De-centralisation in primary care – health and social care.

Anticipatory care programme.

England.

SHAs, PCTs, Foundation hospitals.

Practice-based commissioning.

Mixed economy in ooh service provision.

“Hard” monitoring in QOF.

Less emphasis on prevention/public health.

Connecting for Health.

Payment by results.

Increasing patient & public involvement.

24-hour nurse-led telephone triage service (NHS 24).

Reducing inequalities.

Banning tobacco advertising.

Setting national standards & streamlining accountability processes.

Unified NHS Boards.

Reduce waiting times.

Services local to need.

Preventative, anticipatory care.

Greater integration – primary and secondary care; primary, community & social care.

Optimise use of new technologies e.g. ehealth.

Support new skill mix options.

Patient & public involvement.

Tackling inequalities.

Supporting long-term conditions.

Anticipatory care programme to reduce health inequalities: Keep Well.

Support self-care for long-term conditions.

Establish health & social care services in communities: Community hospitals; Community Health Partnerships.

Reduce waiting times.

Electronic Health Record and Emergency Care Summary.

Streamline unscheduled care.

Support remote & rural health care.

CHPs/CHCPs.

New organisations developed to manage a wide range of community based health services.

Bring together primary care (including general practice), community care and social care.

Co-terminous with local government boundaries.

41 established.

Priorities:

A shifting of the balance of care to more local settings and

Improvement in the health of local people.

Reducing inequalities in health.

Keep Well.

Targeting hard-to-reach populations:

45 – 64 year olds in most deprived communities.

Improve reach and engagement.

Once engaged – improved primary prevention.

improved secondary prevention.

Piloted in 5 CHPs; 7 more later this year.

Over 90 practices involved.

What will be the outcome for patients; for practices; for the wider NHS?

Where do we go from here?

Conclusions.

Scotland continues to reject a marketised approach to health care.

Greater move towards health and social care integration.

Anticipatory care high on agenda.

Governance and monitoring low-key, but may not remain like that.

Need to address twin issues of inequality and deprivation continues to influence Scottish health policy.

Dave BarryUS columnist & humorist (1947 - )

We Americans live in a nation where the medical-care system is second to none in the world, unless you count maybe 25 or 30 little scuzzball countries like Scotland that we could vaporize in seconds if we felt like it.