1. Primary Healthcare – Priorities for Improvement
18th November 2014
Primary Healthcare – Priorities for Improvement
Paul Gimson, 1000Livesi

2. Excercise
On your tables, agree and sketch a picture of ‘primary care’ as you see it now...

3. Summary The Evidence Primary Care CEO Conference Prudent Primary Care
NUKA
Welsh Government Primary Care Plan

4. What is Primary Care?
First contact, continuous, comprehensive and co-ordinated care provided to individuals and populations undifferentiated by age, gender, disease and organ systems
The service should be:
Comprehensive, person-centred, population oriented, coordinated, accessible, safe and high quality.
Primary Care in Wales: Rapid review of models and policy

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6. Increasing and complex demand on primary care
Our population is increasing and getting older
More people are being diagnosed with one or more long-term health conditions like diabetes and dementia
Frail and older people increasingly have more complex needs
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8. What does the evidence say?
In order for primary and community care to be delivered from a population health perspective then;
Provision would need to be scaled up, delivering through federations/super-partnerships, and variation and inequality would need to be reduced.
Planning and commissioning needs to be needs based, make better use of community assets and aim to integrate services
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9. What does the evidence say
For this to happen, and for change to accelerate, there needs to be;
A clear vision
Better engagement with citizens and stakeholders
Pragmatic change at all levels
A plan that is relevant to all
Resources – including people
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10. Primary Care CEO Conference
Vision
Priority
Workforce
Local mapping of resource and infrastructure
Outcome data
Integration – planning, finance, estates, services, LHB structure and leadership
IT and information sharing
Co-production
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11. How do the principles of Prudent Healthcare apply to primary care
Minimise avoidable harm
Carry out the minimum appropriate intervention
Promote equity between the people who provide and use the services
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12. Prudent Primary Care
Three things you may not know about prudent healthcare
It directly involves patients in designing their own care and participating in co-creating services
It focuses on obtaining the best outcomes for patients, discarding practices which are of marginal or no benefit, or may even cause harm
It is allied with a global movement seeking to reduce harmful overmedicalisation

13. Implementing prudent healthcare in primary care
Greater focus on prevention, promoting wellness and healthy behaviours, improving community cohesion
Prudent Prescribing
Shared goal setting and shared decision making (better outcomes & use of evidence)
Working with secondary care – alternatives to referral, improving access to specialists & patient experience
Refraining from interventions with low clinical value and no robust evidence base
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14. Prudent Primary Care – Next steps
SDM – Opportunity, resource and capacity
Using evidence effectively to reflect co-morbidities, elderly population and polypharmacy
Co-production – information and resource to support collaboration and integration
Prudent prescribing and tackling polypharmacy
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15. Evidence Based Medicine: a movement in Crisis?
BMJ 13th June 2014, T Greenhalgh, N Maskrey and J Howick
Talks about the unintended consequences of ‘Evidence Based Medicine’
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16. The problem with EBM? Distortion of the brand Too much evidence
Marginal gains and a shift from disease to risk
Overemphasis on following algorithmic rules
Poor fit for multimorbidity
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17. A

18. A return to real evidence based medicine
Individualised for the patient
Shared decision making
Co-production
Judgment not rules
Aligned with professional, relationship based care
Public Health Dimension
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20. The Nuka System of Care
Recognised as one of the most successful primary care systems in the World
A community-led model of ‘customer ownership’
Health outcomes of community significantly improved
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21. Nuka
95% population have access to a primary care integrated team (up from 35%)
Reduction from 4-week delay to schedule an appointment to same-day access
Staff turnover a quarter of what it was five years later
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22. NUKA – Changing the Primary Care Paradigm
Outcome not income
Person not disease
Population not process
Service not practice
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23. Lessons from NUKA for NHS Wales?
The importance of personal, longitudinal holistic care with small teams rather than individuals
The development of multi-disciplinary teams with a focus on early intervention and meeting the needs of patients who live with self-limiting illness and chronic conditions
The importance of appropriate skills and team building; pharmaceutical advice, nursing care, administrative support
Using thorough, frequent metrics to monitor service provision and individual clinical standards
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24. How? Leadership Organisational development Clinical Engagement
Values driven working and recruitment culture
A greater emphasis on patient-set goals and priorities
Exploring lifestyle interventions rather than medical responses
Understanding (and delivering) what matters most to people who use the service
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26. WG – Primary Care Plan From the Ministers introduction;
“No GP shuold routinely be undertaking any activity which could, just as appropriately be undertaken by an advanced nurse, a clinical pharmacist or an advanced practioner paramedic”
“At the centre of this plan is the notion of co-production – the recognition that health outcomes are maximised when the contribution of the patients as well as practitioners is captured and put to work”
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27. WG Plan – 5 areas for action
Planning care locally
Improving access and quality
Equitable access
A skilled local workforce
Strong leadership
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29. To Throw into the mix... RCGP – Putting patients first
GPC Wales – Prescription for a Healthy Future
Royal Pharmaceutical Society Wales – Your Care Your Medicines
Trusted to Care and others
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30. So...
Given all that – Sketch a picture of how you think primary care might look when all of ‘this’ becomes reality
What are the major differences?
How can we move (at scale and pace) from one picture to another?
What are the priority areas of change?

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