mid life practice Flashcards
b) Quantifying the health of patients is a very difficult task, with various complexities which impact both the doctor and patient perspectives especially when tackling complex diseases such as CVD.
Name the algorithm used to calculate a persons risk of developing stroke or heart attack (1 mark)
q risk
/ qrisk3
c) As time has gone on, there has been a growing demand to assess the quality of primary care health outcomes. One such measure was introduced in April of 2004, known as QOFs.
What does QOF stand for? (1 mark)
Quality Outcomes Framework
d) Name three potential advantages to measuring primary care quality via QOFs (3 marks)
- Reduce variability within practice (aka quality control)
- Drive up standards
- Provide data
- Reward ‘good’ practice (incentivization)
- Embed health promotion into primary care practice
e) Name three unintended consequences to using QOFs in primary care (3 marks)
- Prioritising certain aspects of health promotion (emphasises profit motive)
- Demotes Patient’s Agenda (no longer patient centric)
- Undermines GPs autonomy
- Encourages overtreatment
- Policy before Evidence (increased bureaucracy etc)
- Under-resourced
- Underlined variability within practices
ADULT HEALTH PROMOTION
WHOSE RESPONSIBILITY?
Government Local Authorities Public Health Hospital Specialists GPs Nurses Dietitians Patients
ADULT HEALTH PROMOTION
IN PRIMARY CARE
- ACCESS TO PATIENTS
- HOLISTIC
- LONG TERM CARE
- CHEAP
- EFFECTIVE
EXPECTATIO NS & TENSIONS IN THE GP CONSULTATI ON
- EXPECTATIONS
- PREVIOUS EXPERIENCES
- OTHER PEOPLE’S EXPERIENCES
• TENSIONS • CHANGING ROLE OF GP AND ALLIED HEALTH CARE PROFESSIONALS • CHANGING ROLE OF PATIENT • CHANGE IN PUBLIC PERCEPTIONS AND TRUST OF THE MEDICAL PROFESSION
CHANGING ROLES OF DOCTORS AND PATIENTS
Doctors – apothecaries to
professionals
Patients to agents– passive to
partners
what is it necessary for doctors to do (authority)
- Ask personal questions
- Conduct intimate examinations
- Perform intrusive investigations
- Persuade people to comply
difference between doctors an patients? (old view)
Doctors-Authoritative - Knowledge • Ethical Principles • Autonomy • Self-governance, • Self-regulation • ?Self-interest • Defensive
Patients - passive
• Little Knowledge
• Trust in clinical and ethical judgement
• See doctors as accountable to themselves
• Passive resistance
key changes in nhs?
FEES FOR PATIENTS • IMPROVEMENTS IN PRIMARY CARE DELIVERY • SHIFT TOWARDS TREATMENT IN PRIMARY CARE • INCREASED SPECIALISATION • CHANGES IN GENERAL MANAGEMENT • INTRODUCTION OF AN INTERNAL MARKET • QUALITY CONTROL • INTRODUCTION OF PATIENT CHARTERS LISTING PATIENTS RIGHTS AND STANDARDS
difference between doctors and patients following changes?
Doctors - educators
• Knowledge (increasingly specialist, competence, EBM)
• Ethical Principles including public health
• Autonomy
• Self-regulation
• Self-interest
• Accountabilty
Patients- informed Consumers • Knowledge more widely available • Ethical Principles (Rationing) • Anti – authoritarian (transparency, doctors as public servants)
NHS
REFORMs 1997-
2001
INDEPENDENT STANDARD SETTING • NICE • CENTRE FOR HEALTH IMPROVEMENT • NATIONAL SERVICE FRAMEWORKS • HEALTH CARE COMMISSION
PATIENT SAFETY
• NATIONAL PATIENT SAFETY AGENCY
• NATIONAL CLINICAL ASSESSMENT
AUTHORITY
IMPROVED PERFORMANCE
• NHS MODERNISATION AGENCY
what is the CURRENT difference between doctors and patients?
Doctor - partners • Knowledge (increasingly specialist, competence, EBM) • Ethical Principles - Reaffirmed • Autonomy • Transparent • Regulated
Patients - experts - Knowledge more widely available • Ethical Principles (Shared) • Accountable (doctors as public servants)
brief summary of change in doctor patient relationship from 60s to 80s to 2000s
doctor:
authoritative, advocate/advisor, educator, facilitator, partner
Patient:
Passive citizens, consumer, informed, particpant, expert
ONGOING
CHANGES TO THE
ROLE OF
GP
GPS AS BUDGET HOLDERS • GPS AS PATIENTS’ MANAGERS, ADVOCATES, GATEKEEPERS • CHARGE OF LONG TERM CARE • HEALTH PROMOTION • PRIMARY & SECONDARY • SCREEN FOR & MANAGE RISK FACTORS • VOLUNTARY • PROVIDERS OF HEALTH INFORMATION IN THE CONTEXT OF THE PANDEMIC • TEAM LEADERS/ COORDINATORS OF THE PRIMARY HEALTH CARE TEAM
ALLIED HEALTH CARE
PROFESSIONALS IN HEALTH
PROMOTION
- HEALTH VISITORS –FOCUS ON CHILDREN
- DISTRICT NURSES – FOCUS ON ELDERLY/HOUSEBOUND
- PRACTICE NURSES
- HEALTH CARE ASSISTANTS
- PHYSICIANS ASSISTANTS
- PARAMEDICS
- PHARMACISTS
- MEDICAL ASSISTANTS
- PRACTICE SPECIFIC
what is q risk
• THE QRISK3 ALGORITHM CALCULATES A PERSON’S RISK
OF DEVELOPING A HEART ATTACK OR STROKE OVER THE
NEXT 10 YEARS. IT PRESENTS THE AVERAGE RISK OF
PEOPLE WITH THE SAME RISK FACTORS AS THOSE
ENTERED FOR THAT PERSON.
• AIM:
• CONSIDER THE PATIENT AND DOCTOR PERSPECTIVES
AROUND THE TENSIONS AROUND HEALTH PROMOTION IN
PRIMARY CARE CONTEXT
• APPRECIATE THE COMPLEXITY AROUND SEEMINGLY
STRAIGHT FORWARD INTERVENTIONS
WHY MEASURE QUALITY OF
PRIMARY CARE?
• QUALITY IMPROVEMENT OR BENCHMARKING: TO DETERMINE
EXISTING QUALITY AND IMPROVEMENT.
• COMPARISONS TO STIMULATE AND MOTIVATE CHANGE
• PAY-FOR-PERFORMANCE SCHEMES
• QUALITY CONTROL: MINIMUM OR INTENDED STANDARDS
• REGULATION: COMPLIANCE WITH LEGAL OR SAFETY
STANDARDS
• TO INFORM SERVICE USERS: TO COMPARE PROVIDERS
• FOR MARKETING : TO HIGHLIGHT AND ADVERTISE A STANDARD
OF QUALITY (E.G. ACCREDITATION)
HOW TO MEASURE QUALITY OF PRIMARY CARE?
• WHAT IS GOING TO BE MEASURED (FOR EXAMPLE, STRUCTURES, PROCESSES OR OUTCOMES)? • HOW IS IT GOING TO BE MEASURED (USING CLINICAL AUDIT, INDICATORS OR PATIENT SURVEYS, TRIALS OR COMPLEX INTERVENTIONS ETC.)? • WHOSE VIEWS ARE BEING REPRESENTED (PATIENTS, HEALTH PROFESSIONALS OR GOVERNMENTS/PAYERS, ETC.) • WHO WILL GET TO SEE THE DATA ONCE THEY HAVE BEEN COLLECTED?
QOF
INTENTIONS
REDUCE VARIABILITY WITHIN PRACTICE • DRIVE UP STANDARDS • PROVIDE DATA • REWARD ‘GOOD’ PRACTICE • EMBED HEALTH PROMOTION INTO PRIMARY CARE PRACTICE
QOF COMPONENTS
Clinical standards - chronic disease areas
including public health
Organisation standards
Patients’ experience
Additional services.
IMPACT OF QOF
• INCENTIVISED CODING & PRACTICE SPECIFIC DATA
• REDUCED VARIABILITY & PERFORMANCE/ ACHIEVEMENT EXCEEDED
EXPECTATIONS (DORAN, T. ET AL., 2006).
• FINANCIAL INCENTIVES GENERATED AN ACCELERATED, BUT NOT LASTING,
IMPROVEMENT OVER-AND-ABOVE EXISTING TRENDS IN QUALITY IMPROVEMENT
IN UK PRIMARY CARE (CAMPBELL, S.M. ET AL., 2009).
• HOWEVER, PATIENT EVALUATIONS OF QUALITY OF CARE ACROSS THE SAME
TIME PERIOD DID NOT CHANGE EXCEPT FOR ASSESSMENTS OF CONTINUITY OF
CARE, WHICH DECLINED.
• INTERVIEWS WITH PATIENTS WITH MANY QOF CONDITIONS SHOWED THAT NO
PATIENT HAD HEARD OF QOF AND MANY FELT UNEASY WITH THEIR DOCTOR BEING PAID INCENTIVES TO DO ROUTINE TASKS (HANNON, K., LESTER, H., AND CAMPBELL, SM., 2012).
• PROVIDED MODEL FOR OTHER LOCAL & NATIONAL INCENTIVES E.G. NHS HEALTH CHECKS, DOAC MONITORING IN PRIMARY CARE
UNINTENDED
CONSEQUENC
ES OF QOFS
• PRIORITISING CERTAIN ASPECTS OF HEALTH PROMOTION • DEMOTES PATIENT’S AGENDA • UNDERMINES GPS AUTONOMY • ENCOURAGES OVERTREATMENT • POLICY BEFORE EVIDENCE • UNDER-RESOURCED • UNDERLINED VARIABILITY WITHIN PRACTICES
QOF AMENDMENTS
Use of guidelines, external choice Reduced amount based on performance Adding areas Guidance on exception reporting Removing organisational indicators
Health promotion in primary care
Finding the story
Population level Research and evidence base Policy changes / Public Health interventions Pharmaceutical industry influence Moral and ethical questions for society: ageing, health economics, Primary Care level Research and evidence base Systems and incentives Consultation level Clinician and patient factors Tensions and conflicts
