Primary Health Care Organisations Evidence; Experience and Belief Terry Findlay APHCRI PHC Roadshow September October 2014
2 Australian Primary Health Care Research Institute Mission To maximise the health and well-being of the community by leading high quality, priority-driven research and supporting its uptake into primary health care policy, programs and services.
3 What have we learnt? Other Countries experience Divisions and Medicare Locals Is it really evidence? Functions instead of models Its all about context Will this context change? Skills and competencies
4 Learning from similar functions not models Adapted from McRae and Parkinson -2013 PHCOs by country Australia Divisions of General Practice (DGP) 1992-2012 Population Health Planning Commissioning or Purchasing Service Provision (or option) Coordination (integration) Quality improvement Practice support Medicare Locals (ML) 2012- (limited) England Primary Care Groups (PCG) 1998-2000 Primary Care Trusts (PCT) 2000-2013 Clinical Commissioning Groups (CCG) 2013- New Zealand Community Health Orgs (CHO) 1970s- Independent Practitioner Associations (IPA) 1993- Primary Health Orgs (PHO) 2001- Ontario, Canada Local Hospital Integration Networks (LHIN) 2006- (limited) Family Health Teams (FHT) 2005- Alberta, Canada Primary Care Networks (PCN) 2003- United States Health Maintenance Orgs (HMO) 1971- Independent Practitioner Orgs (IPA) 1990s- Accountable Care Orgs (ACO) 2012-
5 UK devolution conclusion except in relation to those areas covered by national targets, variations in performance of the health service within England are greater across many metrics than variations between England and the other three UK countries this suggests that, other than target setting, which all countries have adopted to a greater or lesser extent, underlying macro policy shaping the health services is to date less influential on performance than local conditions such as quality of staff, funding, availability of facilities, health needs and historical legacies of inequalities. The four health systems of the United Kingdom: how do they compare? 2014 Gwyn Bevan, Marina Karanikolos, Jo Exley, Ellen Nolte, Sheelah Connolly and Nicholas Mays http://www.nuffieldtrust.org.uk/sites/files/nuffield/140411_four_countries_health_systems_full_report.p df
6 Primary Health Networks: what we know Outcomes PHNs charged with improving patient outcomes through working collaborative with providers and services Focus on measureable outcomes aligned to LHN outcomes and national priorities General Practice Paramount role Clinical Councils Structure and Process Function Skills based Board Responsive Engaging (Clinical Councils, Community Advisory Committees) Patient Focused Population Health Needs assessment and planning Predominantly purchasing rather than commissioning? Integrate care across the entire health system Service provision ONLY when there is demonstrable market failure, significant economies of scale or absence of services
7 PHNs: core functions Population health Undertake population health needs assessment Local Priorities Plan health services based upon identified need Integration With GPs Across entire health system With established local and national clinical bodies Clinical councils Community advisory committees Purchasing Undertake purchasing activities Integrate care across the entire health system Only provide services where demonstrable market failure exists Quality Improvement Practice Support Information Workforce - Engagement
8 Core Function: Population health Evidence/ Data Health needs assessment Health profiling Risk stratification Preventive health Partnership working Health promotion Patient engagement Stakeholder engagement
9 Assessment of organisational needs in face of new population health roles (UK) Education and training available to a wide range of staff to provide public health [sic] skills Broadening public health [sic] skills and dissemination of a public health culture within PCTs. Assistance with Health Needs Assessment Emphasis on partnership working Information management Evidence based practice Web-based public health [sic] materials and information technology 2002 UK Health Development Agency commissioned assessment of new PCT organisations opportunities and barriers to delivering population health roles and functions and their development needs in order to fulfil them; Public Health 117 (2003) 157 164
10 Population Health; service planning and purchasing. Commissioning? 1 4 2 3 AML Alliance June 2012
11 Core Function: Commissioning/Purchasing What s in a name Primary or Secondary Mandate or local delegation Capabilities required built on cycle Needs assessment Service development Provider Engagement Evaluation
12 Relevant key learnings from overseas New Zealand IPAs: engaged GPs = bottom up capacity building in response to top down policy change Some IPA evolution into support organisations USA Investment into developing the organisation and its staff is key; leadership/ management/ infrastructure England (WCC) Commissioning competencies are unique and essential skill sets Commissioning itself costs; has to be invested in England (CCG) Early evidence of improved relationships between primary and secondary care clinicians
13 Priorities National and Local Service gaps; where no/limited service exists and/or access and quality Benefit analysis and risk stratification Alignment with partners Integration
14 Lessons on priority setting (USA/England) Local approaches to priority setting, very much influenced by national Policy Priority-setting tools useful for process of decision making, but also for promoting debate about health spending and services at a local level Public engagement in priority setting difficult to secure, but important, especially when disinvestment is required PCTs (UK) struggled to engage acute trusts in priority setting, making decisions hard to implement Practice-based commissioning (previous UK policy) helped with clinical engagement in priority setting, including across primary and secondary care; bodes well for clinical commissioning groups (new policy) Effective priority setting needs significant project management and other support Casalino L. GP commissioning in the NHS in England: ten suggestions from the United States. Nuffield Trust. 2011 http://www.nuffieldtrust.org.uk/sites/files/nuffield/publication/gp-commissioning-in-the-nhs-in-england-tensuggestions.pdf
Priority Areas The King s Fund identified 10 priority areas for commissioning. [Chris Naylor et al., 2013, #32832]
16 Core function: Integration What does it mean? Where to start Partnerships Engagement Clinical pathway development Information and ehealth
17 Types of Integration Systemic integration (consistent privacy policies, pooled funding arrangements) Organisational integration (e.g. joint ventures, liaison officers, service networks) Functional integration (shared records, service directories, single point of contact for referrals) Integrated care to the patient/ services to the community Clinical integration Service integration (multi-disciplinary teams, one stop shops ) (shared care programs, use of clinical pathways) Normative integration (multi-disciplinary training and education)
18 Integration lessons from ACOs (USA) Focus on high users risk stratification Case management and care co-ordination Information sharing and technology Engage patients in self management Aligned payments/incentives/purchasing Shared partner objectives Partnerships
19 Engagement Professional engagement; culture and investment Clinical leadership Patient engagement and support strategies Community and stakeholder engagement
20 Context of PHN operations What stays the same? Health service business models and funding systems Financial constraints DoH accountability imperatives Limited levers Access to information Performance attribution
21 Context of PHN operations What may be different? State Roles Local delegation Blended payment models Role of Health Insurers E Health Cost and Access Performance Measures
Healthy Communities reports
23 Soft Power the ability to attract and co-opt rather than coerce, use force or give money as a means of persuasion
24 PHN essential organisational capabilities Leadership; clinical & managerial Inclusive governance and priority setting Relationship building and management Partnership vision, culture and practice Planning, data collection and analysis Purchasing/Commissioning Change Management