MIGRAINE IN PRIMARY CARE ADVISORS Implications of the new GP contract to headache management

Overview Review of the new GP contract Identifying opportunities in the new contract Designing audits based on targets in the contract

Review of the new GP contract

Overview More flexible service provision Support of human resources and infrastructure modernisation Investing in primary care services Rewarding clinical and organisational quality Providing better services for patients Implementation

More flexible service provision Address issues of practice workload Service categorisation –Essential services: compulsory –Additional services: usually provided –Enhanced services: specialist and optional PCOs ensure patient access to services not compromised GPs have balance between work and personal commitments PCOs take full responsibility for out-of-hours services PCOs can provide or commission services

Support of human resources and infrastructure modernisation Improve working lives of GPs –3-module approach: skills, knowledge and experience –Reward experience –Support work / life balance Enhance practice management Additional support for rural and remote practices Practice infrastructure modernised –New / modernised premises –Investment in information management and technology (IM&T) Flexible service provision by supported individuals

Human resource development New career structure –Skills development, primarily for newly qualified GPs (skills rather than titles) –Special interest development – e.g. GPwSI services –Clinical leadership – e.g. education, mentoring, governance, appraisal Learning and personal development supported through protected time –Practices to develop support systems Proper funding of appraisals in PCOs

Supporting practice staff: nurses Quality framework applies to practice team, rather than the GP in isolation Nurses supported to take on advanced and specialised roles –Clinical supervision and appraisal –Access to professional development and IM&T –Roles in first contact care, chronic disease management and preventive services

Supporting other practice staff Support practices to develop greater skill mix –Registered nurses –Pharmacists –Allied health professionals Professionals work at all levels as part of the practice team –Involved in practice decision making that impacts on their work

Investing in primary care services Guaranteed level of resources allocated through PCOs Average practice income will rise Practices have flexibility in how they spend money received Money will flow according to patient need Investment in advanced services Separate allocations to premises Definition of pensionable pay broadened –Real benefit

Service categorisation Essential services (compulsory) Management of ill patients back to health, reflecting patient choice General management of the terminally ill Management of chronic disease in discussion with the patient

Service categorisation Additional services (opt out possible) Cervical screening Contraception Vaccinations and immunisations Child health surveillance Maternity services Minor surgery

Service categorisation Enhanced services (specialist and optional) Essential/advanced services delivered to a higher standard –e.g. extended minor surgery More specialist services –GPwSIs –Primary-secondary care interface –Specific local needs –Piloting innovative services

Out-of-hours service Possible options NHS Direct / 24 GP co-ops NHS walk-in centres Practice partnerships Paramedics Pharmacists A&E departments with GPs and primary care nurses Commercial deputising services Social work services

Rewarding clinical and organisational quality Major focus on quality and outcomes Rewards practices for the quality of care delivered to patients The framework –Clinical domain –Organisational domain –Patient experience domain –Additional services domain Implemented by annual review, including a practice report and a visit by the PCO

Clinical domain Essential services but provided at enhanced level CHD, including LVD Stroke and TIA Hypertension Hypothyroidism Diabetes Mental health COPD Asthma Epilepsy Cancer No headache!

Indicators for each domain Based on best available evidence –But evidence may change and has to be updated Number kept to a minimum Data should be useful for patient care –Not for audit only Obtainable from existing practice systems

Clinical indicators 1.Structure: Medical records 2.Process: Diagnosis / initial management 3.Outcome: Ongoing management

Organisational domain Records and information Communicating with patients –Only two questionnaires currently approved Education and training Medicines management Clinical and practice management

Patient experience domain Patient survey Consultation length Major opportunity for headache?

Additional services domain Cervical screening Child health surveillance Maternity services Contraceptive services

Providing better services for patients Services designed around patients’ needs Patient Services Guarantee ensure patients continue to receive primary care services Patients register with practice rather than GP –But retain the choice to see an individual GP Empowering patients to manage their own conditions –Improving public education –Developing the skill mix across primary care –Developing ‘expert patient’ schemes –Working with community pharmacies

Benefits to patients Increased resources available Allocation of resources according to patient need Choice of practice and practitioner Patient Services Guarantee Aim for higher quality services Feedback via practice surveys and involvement in service development Initiatives for patients to manage demand for services Consultations at 10-minute intervals

Patient Services Guarantee Access to wide range of services in primary care Most practices deliver the full range of additional services Extending patient choice –Choice of service provider –Choice of additional service provider (when practice opts out) –Availability of parallel additional services –Choice of advanced service provider

Working in partnership Development of management and education programmes for self-care Development and support of Expert Patient initiatives Supporting non-GP chronic disease management schemes Promotion of Doctor Patient Partnership and health charity initiatives Promoting education of young people via the National Curriculum` –Possible major opportunity

Implementation NHS contract between the local PCO and the practice –Services provided –Level of quality –Infrastructure and support –Financial resources Teamwork encouraged with GPs and other professionals

Alternative providers PCOs can commission or provide services –Maximum flexibility to commission enhanced services, including from the private sector –Essential primary care may also be provided by GP walk-in centres –From 2006, what are now specialist services can be provided in primary care

Contract review Formal review process –Annual return from the practice –Annual review, typically involving a visit Evidence-based review in the medium to long term

First steps Doctors’ and Dentists’ Review Body asked to endorse the agreement Primary legislation introduced Contract implemented in a phased way Substantial implementation will occur in 2003/04 Problem with underfunding

Identifying opportunities in the new contract

Concepts In the future the career of medicine will involve collecting competencies –Core –Specific Developing relative competencies in headache management –Specialist GP (GPSI) –General GP –Nurses –Pharmacists Service delivery

Initiatives relevant for headache management - 1 Management of chronic disease in discussion with the patient (essential service) –Communicating with patients a key organisational domain –Improving public education –Patient input via practice surveys and involvement in service development –Bringing general GPs, nurses and others up to standards MIPCA guidelines for migraine and CDH emphasise patient-doctor partnership

Initiatives relevant for headache management - 2 Enhanced services encourage development of more specialist services –GPSI schemes –Primary-secondary care interface –Clinical leadership schemes MIPCA guidelines for GPSI in headache and setting up headache clinics in primary care

Initiatives relevant for headache management - 3 Education and training a key organisational domain –Learning and personal development supported through protected time –Education and mentoring a key part of clinical leadership –Improving public education and promoting education of young people in schools Opportunity for development of MIPCA diploma for headache education

Initiatives relevant for headache management - 4 Development and support of ‘expert patient’ schemes –Promotion of health charity initiatives MAA is funded to provide a specialist patient programme for headache

Initiatives relevant for headache management - 5 Supporting practice staff –Quality framework applies to practice team rather than to GP –Nurses supported to take on advanced and specialised roles First contact care, chronic disease management and preventive services –Pharmacist and allied professionals included in practice team –Teamwork encouraged between GPs and other professionals MIPCA guidelines for nurses and pharmacists, and encouragement of the primary care headache team Lobby for NICE headache guidelines via Headache UK and/or SIGN

Pharmacist Community nurse Optician Dentist Complementary practitioner Patient Primary care physician Practice nurse Physician with expertise in headache: GP; PCT; specialist Ancillary staff Primary care Specialist care Associate teamCore team Copyright MIPCA 2002, all rights reserved

Initiatives relevant for headache interventions Headache is not one of the clinical domains Lobby to include headache MIPCA guidelines comply with clinical and organisational indicators –Based on best available evidence –Assessment based on diagnosis and initial and ongoing management –Patient communication important –Obtain NICE endorsement to raise status of headache

Production of educational packages Education and training of professionals and the public to be supported MIPCA plans to develop a modular education programme for headache –GPSIs –GPs –Nurses and other professionals Courses for educators of professionals and the public (training the trainer)? –Specialist patients

Outputs for governance Audits –Clinical indicators –Patient surveys –Evaluating professional development Education and training Link with RCP to demonstrate that specialist standards are being met –Appraisal

Design of audits

Quality indicators for clinical domains Based on best available evidence Data needs to be useful for patient care, and not just for audits Indicators –Medical records –Diagnosis –Initial management –Ongoing management Patient surveys

Epilepsy Records: –Register of patients receiving drug treatment Ongoing management: –Seizure frequency over past 15 months for patients (≥ 16 y) on drug treatment –Record of medication review over past 15 months for patients (≥ 16 y) on drug treatment –Proportion of patients (≥ 16 y) on drug treatment convulsion free for last 12 months

Asthma Records: –Register of patients receiving drug treatment for asthma over previous 12 months Initial management: –Proportion of patients (≥ 8 y) with diagnosis confirmed by specific testing Ongoing management: –Smoking status (14-19 y and ≥ 20 y) –Smoking cessation advice given –Asthma advice given over past 15 months –Record of influenza immunisation in preceding Autumn / Winter

Possible audits for headache Clinical indicators Education and training Effects on practice Management of audits

Clinical indicators Records Register of patients with headache Register of patients receiving drug treatment for headache

Clinical indicators Diagnosis / initial management Proportion of patients diagnosed with different headache subtypes (migraine, TTH, CDH, cluster, sinister) over the past 12 months Record of medication history Record of co-morbidities Patients self-referred / referred by another professional (e.g. pharmacist) Patients given management education / advice Patients sent for procedures / referral Patients given a headache diary or other questionnaires to complete Patients treated with prescribed drugs: acute and prophylactic

Clinical indicators Ongoing management Register of follow-up appointments Record of headache status Medication compliance review Completion of headache diaries and other questionnaires Record of patients whose treatment (acute and prophylactic) was changed Success of initial and follow-up medications

Education and training Record of personal learning plans Annual appraisals of primary care team (GPs, nurses, others) Review of patient surveys

Effects on practice Record of practice team arrangements Record of time and resources spent dealing with headache Number of patients diagnosed Number of patients on acute and preventive treatments

Audit toolbox Record forms –Headache history questionnaires –Patient checklists –Headache diaries –Impact and other questionnaires Audits conducted by nurses and other practice staff