1. 6 th 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

2. Content … Priorities for Primary Care Effectiveness of Primary Care Evaluation Conclusion

3. 3 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

4. Factors Influencing Care Government Patients Physicians choice satisfaction/ quality equity costs standards clinical freedom

5. 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

6. 6 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. 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. 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

9. 9 Responsiveness to Population & Accountability Define core population need –Health needs assessments –Comparative audits Accountability to patients Accountability to the managers Accountability to the profession

10. 10 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

11. 11 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

12. 12

13. 13 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

14. 14 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

15. 15 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

16. 16 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

17. Quality Integration Choice Costs Change Organisational Behaviours Change Physicians’ Behaviours

18. 18 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

19. 19 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

20. 20 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

21. 21

22. 22 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.

23. 23 Shukran Jazeelan Elizabeth A. Dubois Wandsworth Teaching PCT, London