Is Family Practice the Same as Primary Care
Primary Medical Care in the United Kingdom
Abstract
Since 1948 health intendance in the United Kingdom (Uk) has been centrally funded through the National Health Service (NHS). The NHS provides both primary and specialist wellness intendance which is largely costless at the point of commitment. Family practitioners are responsible for registered populations of patients and typically work in groups of four–half dozen cocky-employed physicians. They rent nurses and a range of other ancillary staff, and human action as gatekeepers to specialist care. Recent reforms include a wide range of national quality improvement initiatives and a pay for performance scheme that accounts for effectually 25% of family practitioners' income. These reforms have been associated with some major improvements in quality, including improved chronic disease management and reduced waiting times for specialist intendance. The four countries of the Uk differ in some of import aspects of health care organisation: proposed reforms in England would movement towards a more market-driven system, with family unit practitioners interim as payers for specialist care and controlling 70% of the NHS budget. The other countries (Scotland, Wales and Northern Ireland) focus more on trying to create surface area-based integrated systems of care.
- Health Care Services
- Health Intendance Systems
- Wellness Policy
- Primary Health Care
- United kingdom
Main Care Models and Payment Systems
Core features of UK primary care have been constant since the National Health Service (NHS) was created in 1948. There is universal registration with a unmarried practice of the patient's choice, and all primary medical intendance is provided by full general practitioners (GPs), which are broadly equivalent to US family unit physicians. Primary and specialist care is almost entirely free at the point of delivery and is funded nationally from full general revenue enhancement; however, there are outpatient prescription charges of £7.20 (Usa$11.60) per item in England, £iii.00 (US$4.80) in Scotland, but there are no prescription charges in Wales. Approximately 90% of items are dispensed to people who are exempt from prescription charges. In that location are additional charges for dental care and intendance provided past opticians. There is a strict divide betwixt master and specialist care: specialists work largely in hospitals, where they provide inpatient treat all and run across new and follow-up patients in clinics, whereas GPs act as gatekeepers to specialists with some small exceptions, including attendance at the emergency department and sexual health service. GPs piece of work in practices, which they usually own, in partnerships of four to 6 physicians, on average. These practices derive the great bulk of their income from contracts to provide NHS patient intendance. Nether these contracts, approximately 75% of practice income comes from capitation, xx% from pay-for-performance (P4P) fees under the Quality and Outcomes Framework (QOF), and 5% from Enhanced Services' contracts for more specialist intendance (for instance, services for those who misuse substances). Using this income, GPs employ staff in any configuration they wish; GPs' take-home pay is the practice'southward profit. Currently, the boilerplate net pay of a GP is slightly more than than the average NHS income of a specialist.
Infrastructure
Workforce and Patterns of Work
General practices remain pocket-size, physician-endemic businesses, but in that location take been significant changes over the final 20 years. Practices have grown from an boilerplate size of 5726 patients in 2000 to 6610 patients in 2010, with the proportion of solo practices falling from 22.8% to 14.5% and the average patient panel per GP falling from 1795 to 1567 over the same catamenia.one There has been a steady increment in nurses employed by GPs and more recent shifts to existing partners employing lower-paid but salaried physicians rather than taking on new profit-sharing partners. Nurses are able to substitute for GPs in many aspects of primary care without a loss of quality,two and the increasing utilize of nurses in chronic disease management has been associated with improvements in quality of care.3 A typical practice squad might now consist of 5 or 6 GPs, ane nurse practitioner, two or 3 practice nurses, and between half dozen and 10 receptionists/administrative staff. In addition, practices work closely with a broader, ofttimes co-located primary health care team that is employed straight by the NHS. This wider team may include district nurses, who providing home nursing care; health visitors, who provide well-kid care; and more than variably midwives, community psychiatric nurses, and allied health professionals. Much less usually, practices have social workers embedded in their team.
Britain primary care is primarily provided through face-to-face consultation on the practice premises with home visits available for those who are unable to travel. In the last 15 years at that place has been an increment in consultation rates, an increase in the proportion of patients seen past nurses, an increase in phone consultations, and a reduced number of home visits. In parallel, there has been an increase in the length of GP consultations (Tabular array 1).4 GPs retain a gatekeeping role, although the speed of access to specialists has improved in recent years, with 80% of patients now getting to see a specialist within 4 weeks compared with 88% in the Us.5
Table 1.
U.k. Full general Practise Consultations, 1995 to 2008forty
It
In 1990, the introduction of payments for reaching cervical cytology and immunization targets required GPs to institute recall mechanisms. Many responded past buying estimator systems; this was facilitated past the NHS, which covered fifty% of the costs if the systems met authorities-defined standards. By the end of the decade, most GPs were using computers to print prescriptions and a substantial minority had made their own clinical record fully electronic. In 2004, the data requirements of QOF P4P system led most GPs to move to full electronic clinical records. The government at that time also moved to cover the full cost of GP figurer systems. Because GP payment has near no fee-for-service element, clinical computer systems have been designed for clinical purposes and to mensurate quality rather than for billing. Many practices have now moved to fully paperless records. Considering records follow the patient when they alter practices and specialists routinely write to GPs subsequently a visit or admission, primary care records, in principle, contain a lifelong record of patient's medical intendance.
Expanse-Based Primary Intendance Organization
GPs are accountable for the intendance they provide through the contract they hold with the NHS. Local NHS administrative organizations, currently Primary Care Trusts in England and Health Boards in Scotland, accept the responsibility for implementing national policy, monitoring practices, and implementing local quality improvement and fiscal incentive schemes. Prescribing is an instance of an expanse in which at that place has been longstanding appointment between practices and larger NHS organizations, starting with feedback of comparative prescribing cost data, which adult into regular educational outreach visits by prescribing advisers, and the cosmos and more than recently incentivization of local prescribing indicators. In England, these organizations are subject to frequent politically driven reorganization that causes repeated disruption; this is sometimes termed re-disorganization.vi,seven
Creating and Sustaining Alter/Transformation
Alter in primary care continues to rely significantly on the entrepreneurialism and professionalism of GPs, although with the back up and leadership from professional organizations such equally the Regal College of GPs, which has historically led primary care standard setting and quality accreditation schemes. However, system-wide change is ordinarily driven by national policy. Despite overall high standards, the gap between the least and near progressive practices remains wide. There are good examples of successful improvement in quality (refer to Quality and Safety), but ii areas that have proved persistently problematic are out-of-hours (OOH) care and improving intendance coordination.
Out-of-Hours Care
Until 2004, GPs had 24-hour responsibleness for the intendance of their registered patients. OOH care was at that fourth dimension largely delivered past area-based cooperatives of GPs, which provided OOH care mainly through dwelling visits. In 2004, the local NHS administrative organizations took over responsibility for OOH care. They most oftentimes contracted intendance to a commercial organisation (sometimes run by local GPs) that employed doctors and an increasing number of nurses and that progressively provided care at purpose-built facilities rather than at the patient'south dwelling house. There has been considerable disquiet over the standard of OOH intendance under these new arrangements,8 particularly in England, where responsibility for OOH care will return to GP leadership in 2013, albeit as the responsibility of Commissioning Consortia rather than individual practices.
Care Coordination
In principle, GPs are responsible for coordinating the care of individual patients, which is facilitated past their gatekeeper role and by having a comprehensive patient tape. International surveys suggest that UK primary intendance is rated high past patients in terms of coordination,9 but existing models of care do non always see the needs of the increasing number of elderly, comorbid, and frail patients in the community. In response, policy has created new services for patients who are at particularly loftier gamble of hospitalization, including the development of predictive risk models to identify patients for intensive example management (by "customs matrons" in England). However, the evidence that these new services are effective is weak; continuity of care becomes more difficult as teams get larger,10 and there is a tension between providing rapid access and personal continuity of care.11 Integration across primary–secondary care and health–social care boundaries, and addressing the needs of increasingly elderly and comorbid populations, remain significant challenges.
Quality and Safety
Quality Improvement Initiatives (Including P4P)
In 1990, the United kingdom introduced modest P4P in primary care in the course of payments for reaching target levels of babyhood immunization and cervical cytology. This led to increased performance followed by a slower reduction in socioeconomic inequalities.12,13 In 1998, the NHS embarked on a widespread programme of quality comeback nether the general heading of "clinical governance."14–xvi This included the evolution of national clinical guidelines and national service frameworks to guide implementation of comeback action; a body to make recommendations about cost-effective treatments in England (Prissy, www.nice.nhs.uk); the introduction of almanac appraisal for all NHS doctors; district-wide audits of clinical intendance, with identifiable data being shared with practices and sometimes with patients; and a range of local financial incentives schemes for quality improvement. These were associated with significant improvements in quality of care.17
In 2004, a new and much more ambitious P4P scheme was introduced in general do, with twenty% to 25% of GPs' income dependent on a circuitous set of ∼75 indicators relating to clinical care and 75 relating to practice organization and patient experience (the QOF).18 Since 2004, new clinical topics accept been introduced and payment thresholds accept been raised gradually. An of import feature of QOF is that GPs can exclude patients if they judge that incentivized care would be inappropriate for particular individuals.19 A scheme to tie GP payments directly to patient feel survey scores was introduced in 2008, but it proved problematic20 and was withdrawn in 2011. In general, QOF financial incentives have produced some increment in the charge per unit of quality comeback for major chronic diseases, but this against a groundwork of quality that was already improving quickly.21 The introduction of QOF has been associated with reduced socioeconomic inequalities in the delivery of care22 and may in some cases have helped to reduce emergency hospital admissions. Public reporting of QOF results is likely to accept contributed to quality improvements aslope financial incentives, and these were probably larger than they needed to be. P4P has changed both the organization of practices and relationships within them,23–26 and it has changed care in means that sometimes take been unfamiliar to and unwelcomed past physicians.27 Measured negative impacts on nonincentivized atmospheric condition seem to take been pocket-sized,28–30 only critics believe that QOF has introduced a negative "tick box" culture into main care.31 Despite contempo improvements, there remains a substantial gap betwixt the all-time and the poorest practices and a range of areas where quality could even so exist improved.32
Commissioning in a Health Care Market and Its Alternatives
Nether proposals to be implemented in England by 2013, consortia of general practices (Clinical Commissioning Consortia) will be given control of two thirds of the entire NHS budget for specialist and infirmary care for their patients,33 though the original proposals are to be modified as a effect of professional and public business organization.34 The government's rationale for giving GPs such power is that they have responsibility for defined populations and are therefore the best placed to identify and encounter those populations' needs. This builds on previous experiments that gave GPs budgets to purchase hospital intendance (GP fundholding), which had some small do good although it may also accept increased inequalities.35–37 In contrast to NHS England's reliance on quasimarket mechanisms and strongly managed, centrally fix targets to drive improvements in quality, the other iii Uk countries (Scotland, Wales, Northern Ireland) have chosen to focus on trying to create more integrated, area-based "unmarried system working," which relies on encouraging professionally led collaboration.38 The reforms in England remain highly controversial, partly because of the expanded part given to GPs with potential conflicts of interest betwixt their twin roles as intendance providers and upkeep holders, and partly because of the increased opportunities for the commercial health care sector that the reforms introduce. It remains unclear which approach will evangelize the best outcomes in the long run, but in all UK countries, past and present governments remain committed to keeping primary care central to the delivery of care in the NHS.
Central Lessons
The United Kingdom has health outcomes that are broadly comparable with other, more plush wellness intendance systems. In that location are, however, some areas of continuing business concern, including mortality for weather that are considered acquiescent to health care and for which the United Kingdom performs worse than many other European countries (though similar to the United states) and outcomes of cancer care.39 The NHS is more often than not highly regarded by the British public, who are largely accepting of the GPs gatekeeping part and surprisingly tolerant of system failures when they occur. Primary intendance remains at the heart of successive governments' health care policies. The cadre strengths of United kingdom main care remain universal registration with a chief intendance practitioner, relatively skillful access to main care in terms of both distribution of GPs and speed of access, gatekeeping to specialist intendance, lifelong primary care records that follow the patient when they motion practices and that are now about e'er electronic, and care that is by and large free at the indicate of delivery. That primary intendance practitioners have responsibleness for a defined population enables them to be held accountable for the quality of care they provide. Quality of care in the U.k. has improved essentially in the last 10 years, almost patently in chronic disease direction, which has been associated with multiple quality improvement strategies, including P4P. Nonetheless, every bit with all health intendance systems, in that location remain many challenges, including providing comprehensive care with and continuity of intendance by a workforce that is increasingly part time. This is because of an increase in the number of both men and women who work part time and to the increasing size of full general practices. At the same time, the demand for continuous comprehensive care is increasing with a growing elderly population with multiple medical conditions.
Notes
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This article was externally peer reviewed.
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Funding: none.
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Prior presentation: This commodity was written as a contribution to an international meeting on the future of primary care in April 2011, convened past the American Association of Family Do and generously funded past the Agency for Healthcare Quality and Research.
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Conflict of interest: Dr Colin Thomé was Primary Care Adviser to the Section of Health during some of the reforms described in this article.
- Received for publication June 26, 2011.
- Revision received Nov 1, 2011.
- Accepted for publication November 21, 2011.
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Source: https://www.jabfm.org/content/25/Suppl_1/S6
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