1. WHO Collaborating Centre Imperial College London Ref 212/2011 Primary Care The UK Experience Professor Salman Rawaf MD PhD FRCP FFPH Chile Primary Care Conference, Santiago 6-7 Dec 2011 s.rawaf@imperial.ac.uk

2. Content: 1.Four Questions 2.The evidence 2. Primary Care led NHS in the UK 3. Current & Future Trends in Primary Care 4. Chile: the context © WHO C Centre, Imperial College London

3. © WHO C Centre, IC London Four questions to address: How to improve users satisfactions with the services? How to ‘develop’ skilled personnel & guarantee its permanence at PHC? How to guarantee access to medicine; provide problem-solving therapeutic and Dx technology? Ch Diseases: which community development strategies that PHC should integrate? 1 2 3 4

4. WHO C Centre, IC London The Evidence

5. © WHO C Centre, IC London Why PHC? Modern Society expect that: - Health is a human right - Access to quality & comprehensive services near home - Personal & Continuity of Care My Doctor - Financial Protection (free at time of Delivery) - Competent Health Professionals

6. WHO World Health Report 2008 WHO C Centre, IC London

7. © WHO C Centre, IC London High Performing Systems Less Well Performing Systems vs Principles: Coverage, Equity, less defined Financial Protection Structure: Primary Care-led Hospital-led Focus: People-centred/ Physician-centred/ Population Health Disease orientated Sustainability: High Low HRH: Competency-based No. Based

8. 40% Healthy 40% Healthy 40% Healthy With Risk Factor(s) 40% Healthy With Risk Factor(s) 10% Acute Illness 10% Disability Rawaf’s Model for Burden of Disease - 2001 In Any Given Population © WHO C Centre, IC London

9. Weak PHC Countries Strong PHC Countries 1970 1980 1990 2000 500 0 1000 OECD Countries: Potential Years Life Lost (PYLL) © WHO C Centre, Imperial College London Source: B Starfield

10. Universal Coverage Total Population A Whole System Approach Equity Social Protection Solidarity (Social Contract) Choice Engagement Universal Coverage Total Population A Whole System Approach Equity Social Protection Solidarity (Social Contract) Choice Engagement

11. Telephone Call (NHS Direct)£16 Family Physician£15 Walk-in-Centre£55 GP with Special Interest£75 Hospital Outpatient£150 Day Care£500 One-Day Admission£1,000 Inpatient (2ndary Care)£5,000 High Specialist Care £20,000 PHC Hosp C Cost-Effectiveness (Intervention cost/case): © WHO C Centre, IC London Source: Wandsworth PCT 2006

12. WHO C Centre, IC London Universal Coverage through PHC

14. © WHO C Centre, Imperial College London Professor S Rawaf  The System  Its Foundation  Structure  Operation & Management  Financing  Performance  Challenges  The Future

15. © WHO C Centre, Imperial College London Professor S Rawaf Nye Bevan (1897-1960) The Architect of the British NHS 1946 (July 1948)

16. © WHO C Centre, Imperial College London Professor S Rawaf A National Health Service… “…to secure equal access to comprehensive healthcare for every individual across the country regardless of their ability to pay” N Bevan, 1946

17. Strong Founding Principles: 1.Funded through Taxation 2.Free at the point of Delivery 3.Comprehensive 4.Equitable 5.Public Involvement © WHO Collaborating Centre, London Professor S Rawaf

18. Strong Health System (1948-Present) Primary Care Hospital Care Public Health © WHO C Collaborating Centre, London Professor S Rawaf

19. © WHO Centre, Imperial College London H P C P C Public Health Fully integrated Health System

20. © WHO C Centre, IC London Source: RCGP 2010, WONCA 2010 The UK General practice  Population Registration  GP (Family Physician)-Based (0.6/1000 p)  A single portal entry to the HS;  Available 24 hours a day;  The first and vital contact  A gate-keeping function (selective referrals);  Long term & the continuity of personal and family care;  Health, Clinical morbidity, Social problems, local needs, small population  Stakeholder to local public health

21. GPGP HOSPITALHOSPITAL 1 2 3 NHS Direct 100% Registration 10% © WHO C Centre, Imperial College London Professor S Rawaf A & E

22. GPGP HOSPITALHOSPITAL 1 2 3 Cost: 10% + 11% 50% Acute, 20% MH Contacts: 80% - 90% 10-20% NHS Direct 100% Registration 10% HV PN DN CPN Patients Group Home Visits Source: S Rawaf 2007 Midwives © WHO Centre, Imperial College London

23. GPGP HOSPITALHOSPITAL 1 2 3 NHS Direct 100% Registration 10% © WHO C Centre, Imperial College London Professor S Rawaf A & E  Power  Responsibility  Control

24. FPFP HOSPITALHOSPITAL 1 2 3 Cost: 10% + 11% 45% Acute, 20% MH + Contacts: 85% - 90% 10-15% Health Line © WHO Collaborating Centre, London Professor S Rawaf

25. © WHO C Centre, Imperial College London Source: Commonwealth Fund, 2007 AustraliaCanadaGermany NZ UK Overall Ranking 2007 3.552 1 Quality Care462.5 1 Right Care562.5 2 Safe Care46342 Coordinated care36421 Pt Centered Care36214 Access35124 Efficiency45321 Equity25431 LH Productive Life1324.5 Health Expenditure Per Capita, 2004 $ 2,8763,1653,0052,0832,546 High Performing systems

26. © WHO Centre, Imperial College London Professor S Rawaf Challenges to UK Health System

27. Wandsworth London Source: ONS Mid 2002 Population Estimates DPH Independent Report 2004 Professor S Rawaf 1. Huge Variations in Population’s needs Accurate Health Needs Assessment

28. © WHO Centre, Imperial College London Source: ippr 2008 2.Ageing Population Health + Social Care (Joint Needs Assessment, Joint Commissioning) Professor S Rawaf Proportion of a single-person households, UK 1971-2021

29. © WHO Centre, Imperial College London Source:McCrone eat al 2008 ippr 2008 Projected Number of People with Depression, UK 2007-2026 Professor S Rawaf 85+ 75-84 3. Changing Burden of Diseases Flexible Service Delivery

30. © WHO Centre, IC London Efficiency – GP Commissioning Groups Public Health & Primary Care Addressing Health & Risks - Advanced QOF How to shift Power? HC to PC Incentives OH & PC: full integration, partial, embed, collaborative..

31. © WHO Centre, Imperial College London Professor S Rawaf Medical Education & Training

32. MBChB MBBS They Need: Structured Training © WHO Centre, Imperial College London Professor S Rawaf

33. 1 2 3 4 5 F1 F2 1 2 3 2 3 4 5 1 A-level University University (Medical School) Foundation School (Virtual) Med/Surg/PH/Diag General Practice PMET Board + R. Colleges (Standards) GM C CST Principle GP Consultant © WHO Centre, Imperial College London Professor S Rawaf

34. Developing Family Medicine Equitable Community-based Infrastructure Equitable Community-based Infrastructure Strong Postgraduate Training Strong Postgraduate Training Solid Undergraduate Learning Solid Undergraduate Learning © WHO Centre, Imperial College London Professor S Rawaf

35. 1 2 New Entrance: Introduce A structured Training Program Family Medicine 3-5 Years.. Iranian Board Current PHC Doctors One Year on-the-Job Training Program Postgraduate Diploma in Family Medicine

36. WHO C Centre, IC London Some key Observations

37. It is the most important factor to convince people about the value of FM  Training  Competencies  Attitude  PCM  Personal-relationship  Public involvement 1. Quality in Family Medicine

38. © WHO Collaborating Centre, London Professor S Rawaf England: Deaths due to Vascular Diseases

39. Page 39 Change in antibiotic prescribing 1995- 1998: GPRD

40. Page 40 % Patients Referred/Year UK US Health Plans

41. Page 41 National Prevalence (England)

42. Page 42 Percentage of patients with diabetes with HbA1C <=7.4% in last 15 months

43. Page 43

44. Page 44

45. WHO C Centre, IC London 2. Incentives

46. Incentive vs No incentive in Family Medicine WHO Centre, IC London Campbell et al. Effects of Pay for Performance on the Quality of Primary Care in England, NEJM 2009 QOF

47. WHO C Centre, IC London Addressing the 4 Questions:

48. © WHO C Centre, IC London Four questions to address: How to improve users satisfactions with the services? 1  Quality,  Person-Centre Med,  Continuity

49. © WHO C Centre, IC London Four questions to address: How to improve users satisfactions with the services? How to ‘develop’ skilled personnel & guarantee its permanence at PHC? 1 2  Incentives  Based Training on FM (Quality),  Competent Workforce (CPD, Revalidation etc)

50. © WHO C Centre, IC London Four questions to address: How to improve users satisfactions with the services? How to ‘develop’ skilled personnel & guarantee its permanence at PHC? How to guarantee access to medicine; provide problem-solving therapeutic and Dx technology? 1 2 3  Strategic & Op Management,  Health Model,  Integrate with public health and hospitals

51. © WHO C Centre, IC London Four questions to address: How to improve users satisfactions with the services? How to ‘develop’ skilled personnel & guarantee its permanence at PHC? How to guarantee access to medicine; provide problem-solving therapeutic and Dx technology? Ch Diseases: which community development strategies that PHC should integrate? 1 2 3 4  Understanding H Needs (HNA),  Integrate PH and PHC

52. WHO C Centre, IC London........ and Finally

53. © WHO Collaborating Centre, London Source: BMJ, 2008

55. Thank you