stephen gilliam presentation wspcr 2010
TRANSCRIPT
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Public health in general practice
Steve Gillam 02.11.10
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Outline
What do we mean by PH in PC Models of primary care Educational challenges Commissioning and other eastern foibles Research agenda
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1. Defining the role Distinguished from biomedical and
humanist traditions Derive from ‘fundamentals’: registered
list, generalist role, referral rights(gatekeeping)
Delivered by different disciplines Historically ‘oppositional’
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Preventive interventions
Primary Health education, behaviour change,
immunisation, welfare benefits advice, community development
Secondary Opportunistic detection of chronic disease,
screening Tertiary
Chronic disease management
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High risk individual and population based strategies for prevention (Rose)
Identify and treat those beyond a threshold for risk factor
Shift the whole population distribution of risk factor
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2. Defining the model
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Public Health Package
Package Package Elements Cost/person/year
(CMH) (USS, 1990)
Expanded programme on immunization, school health ( including deworming), micronutrient supplementation, health education, nutrition, family planning, tobacco and alcohol control, disease surveillance, vector control, aids prevention
Short course (DOTS) tuberculosis treatment ($0.6), management of the sick child ($1.6), prenatal and delivery care ($3.8), family planning and sexually transmitted diseases treatment ($1.1), limited care for other ailments ($0.7)
Total $12
$4.2
$7.8 Minimum essential clinical services
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QOF Health gains Real but modest gains in some areas, e.g. asthma, DM
No definite improvement in CHD related to QOF
Better recording in QOF but not untargeted areas
No improvement in outcomes, except possibly epilepsy
N Engl J Med 2009;361:368-78.
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Population health and equity Inequalities related to deprivation slowly narrowing
Reductions in age-related differences for CVD/diabetes
Variable effects for e.g. gender related differences in CHD
Dixon, Khachatryan & Boyce. The public health impact, In Gillam & Siriwardena (eds) The Quality and Outcomes Framework, Radcliffe, Oxford 2010.
Lancet 2008; 372: 728–36
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QOF scores nationally (% total points) and changes in exception reporting rates 2004-2009
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QOF balance sheet Improved data recording and analysis
Modest health benefits for individuals and populations
Narrowing of inequalities in processes of health care
Opportunity costs contested
Unintended consequences: on workforce, professionalism, ‘McDonaldisation’
Re-defined meaning of quality
Tyranny of evidence
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Community Oriented Primary Care
“The community general practitioner...” Julian Tudor Hart. A new kind of doctor. London, Merlin Press 1988.
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3. nMRCGP curriculum statement
GPs have a responsibility for the community in which they work, which extends beyond the consultation with an individual patient. The work of family doctors is determined by the makeup of the community and therefore they must understand the potentials and limitations of the community in which they work and its character in terms of socio-economic and health features. The GP is in a position to consider many of the issues and how they interrelate, and the importance of this within the community. In all societies healthcare systems are being rationed, and doctors are being involved in the rationing decisions; they have an ethical and moral duty to influence health policy in the community.
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Capacity building
Overcoming obstacles Political/ideological Contractual Undergraduate training PH in the nMRCGP Organisational turbulence QOF and the biomedical model
New models of training
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Examples of PH related skills
Health needs assessment Technology/options appraisal Evidence based health care Data interpretation Audit Health services evaluation Strategic development/planning
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4. Genealogy of PCBC GP Fundholding Total purchasing
Locality purchasing
Primary Care Groups
Primary Care Trusts
Practice Based Commissioning
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Stages in evolution/development of PBC
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NHS structure - new
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Three domains of Public Health
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5. The research agenda
Primary care-oriented systems are associated with
More preventive interventions Better health outcomes Greater patient satisfaction Reduced costs of health care Reduced use of secondary sector
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Research priorities
Practice-based research, e.g. meaning of symptoms, continuity, MUPS, etc
Population health impact of different models of PHC
Educational research in PH/PC Planning/service development role Policy research – impact of new white papers
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Summary
Public health roles in general practice: preventive and managerial
Obstacles to be overcome in realising the GP/PH role
Implications for GP training New models of primary care delivery will emerge Multifaceted research agenda