Public Health
(1992), 106,357-366
© The Society of Public Health, 1992
General Practitioners and Public Health J. A. G. Paris, MRCP, 1 A. P. Wakeman, MRCGP 1 and R. K. Griffiths, FFCM 2
7Registrars in Public Health Medicine, Institute of Public and Environmental Health, (Formerly Principals in General Practice, Birmingham Family Practitioner Committee), 2Director, Institute of Public and Environmental Health, Health Services Research Centre, The Medical School, University of Birmingham, Edgbaston, Birmingham B 15 27-1-
Family Health Service Authorities (FHSAs), since 1st April 1991, have been both 'managed', by the Regional Health Authority, and 'managing', their contractor services. Both situations are relatively new to them, their Region and the contractors. We examine the opportunities and potential problems of this major strategic change. These relate to: (i) the establishment of effective coordination between providers of primary care services; (2) the establishment of minimum basic standards of care and administration for GPs (based on those set for training practices by the Regional Advisors in General Practice); (3) the development and validation of a data collection system from General Practice which could be used to establish a morbidity database from general practice as a means of health needs assessment as well as for performance review. Introduction Family Health Service Authorities ( F H S A s ) and hence general practitioner services b e c a m e accountable to the Regional H e a l t h Authorities ( R H A s ) f r o m 1st April 1991.1 This presents an opportunity for setting specific regional targets in primary care based on assessment of the needs of the population and the quality of service provided. T h e joint role of F H S A s with District Health Authorities ( D H A s ) in needs assessment has b e e n emphasised by the N H S m a n a g e m e n t executive. 2 The 1990 G P contract places great emphasis on population surveillance 3,4 (see T a b l e I). F H S A s are responsible for monitoring claims m a d e for p a y m e n t for, and setting the protocols of, health p r o m o t i o n clinics and the audit of quality through newly created Medical Audit Advisory G r o u p s . This change, from administration of general practice through Family Practitioner C o m m i t t e e s (FPCs) directly supervised by the D e p a r t m e n t of H e a l t h ( D o l l ) , to m a n a g e m e n t of G P primary care services by F H S A s under the direction of Regional Health Authorities, has taken place in the face of considerable opposition from G P representatives. 5,6 In contrast the shift in emphasis, clinical and financial, f r o m disease intervention to population surveillance, reflected opinion within the profession and was, on the whole, welcomed.
Correspondence to: Dr J Paris.
358
J. A. G. Paris et al. Table I
Summary preventative tasks performed by GPs after 1st April 1990
Task
Age range (years)
Offer check up appt. all patients Offer check up visit Offer check up on new patients Health promotion clinics Paediatric surveillance lmmunisation of children Cervical cytology in target group
16-74 75 and above all ages all ages 0-5 0-5 25-64
Frequency
(C)ompulsory (V)oluntary
Triennial Annual Within 3 months
C C C
Agree protocol c FHSA Agree protocol c DHA
V V*
As per DHA protocol Every five years
Vt Vt
*Only doctors accepted onto paediatric surveillance list paid a fee. tTargets of 70% and 90% for immunisation and 50% and 80% for cervical cytology qualify for high and low payments respectively.
Problems
The G P contract
Crucial elements of the contract are voluntary so some general practitioners may choose not to participate, particularly because there are contradictions between the new contractual requirements and changes in the system of remuneration. For instance, the proportional shift of payments from allowances to lists could encourage the accumulation of large lists and good incomes despite the absence of the provision of important extra preventative services. The absence of a link between deprivation payments and standards of care removes the incentive to upgrade practices in areas of greatest need. The high target levels necessary for payments may dissuade some practices from continuing with or investing in immunisation and cervical cytology services. Health promotion and preventative care
The absence of cash limits for health promotion clinic payments in general practice has resulted in much new activity which has not as yet been validated. Amounts spent are likely to be large (£1.6 million for Birmingham 1991-92. Personal communication Birmingham F H S A ) . Table II lists the payments made to general practitioners from 1st April 1991 for preventative services. 7 The criteria for health promotion clinic approval, for the surveillance examinations of new patients, the elderly and the triennial check offered to 16-74-year-olds are decided locally under national guidelines. The objectives of these services are not clearly defined. Are they simply designed to raise the standard of detection of asymptomatic disease and life style problems with the provision of appropriate advice, as suggested in the introduction to the 1990 Contract? 3,4 Is there also the intention to introduce a more direct 'public health' role into primary care as envisaged by Tudor Hart? 8'9 If this is the case do R H A s have a strategic role in primary care, setting minimum standards, deciding health promotion targets and giving guidance on disease management and health promotion protocols?
359
GPs and Public Health
Table II
Preventative task payments to GPs from 1st January 1991
Task
Payment (£)
Offer check up appt. all patients Offer check up visit Offer check up on new patients Health Promotion clinics Immunisation of children: Diphtheria/tetanus 90% 70% 90% Polio/pertussis 70% Measles/mumps/rubella 90% 70% 90% Preschool booster 70% Total fees payable to GPs for complete immunisation Cervical cytology 80% 50%
None None 5.80
45.00 target target target target target target target target
600.00 200.00 600.00 200.00 600.00 200.00 600.00 200.00 2400.00
target target
2280.00 760.00
Unit of payment
Per patient seen in time Per clinic (8-10 people) Per 22 two-yr-olds/annum Per 22 two-yr-olds/annum Per 22 two-yr-olds/annum Per 22 two-yr-olds/annum Per 22 two-yr-olds/annum Per 22 two-yr-olds/annum Per 22 five-yr-olds/annum Per 22 five-yr-olds/annum For each cohort of 22 children age range 0-5 yrs Per 430 eligible women/annum Per 430 eligible women/annum
Whither the D H A c o m m u n i t y units?
There is a substantial overlap in service responsibilities of District Health Authority ( D H A ) Community Units and general practitioners. Both have responsibility for health promotion and disease prevention programmes. D H A s are required to pick up those patients requiring immunisations, cervical cytology, family planning and paediatric surveillance not provided for by GPs. Indeed they have been required by the D o l l not to cut Family Planning Services so as to provide choice (and duplication) in this field. 1° Do we also need a choice of health promoter, community nurse, etc.? Further, whereas general practitioners are accountable to F H S A s for immunisation and cervical cytology services and targets, the overall responsibility for both services still resides with the D H A s who account to R H A s . Thus the main providers of the programme are not directly accountable to the body responsible for its implementation. Recent data show that inner city doctors are finding it difficult to reach their targets. 11 The m o n e y that would have been paid to these doctors is lost to the health service and no additional funds are made available to D H A s responsible for buying an alternative service. Neighbourhood or list-centred primary care or both?
The organisation of primary care by neighbourhood was favoured by the Community Nursing review team. 12 Community services, run in parallel with the 'list' system of general practice (and hospital referrals), can cause discontent where practices straddle D H A boundaries. Personal choice of family doctor does not guarantee choice of service provider in or out of hospital. The presence of two denominators of primary care provision, the F H S A register and the D H A population, raises important issues now that both bodies have managerial functions.
360
J.A.G.
Paris et al.
Will the GP list or the DHA boundary decide who provides care? Many DHAs provide community services to patients outside their boundaries if they are on the list of their resident practices. Accurate needs assessment based on neighbourhoods will depend on close cooperation between DHAs, FHSAs and general practitioners. The presence of fund-holding practices adds an unpredictable variable for assessing both service need and finance availability for the local DHA from whose fund allocation the GP budget allocation will be drawn.13 The R H A must now take notice of these problems because it can propose to change the boundaries and hold all of the relevant authorities to account. Needs assessment data
The pressure on DHAs from cash limits, an ageing population and improving but expensive technology has placed great emphasis on population health needs assessment. The present system of population surveillance and health needs assessment is centred on secondary and tertiary care and depends largely on mortality and morbidity statistics from the Office of Population Census and Surveys (OPCS) and data obtained locally from hospital activity returns, waiting lists etc. 14,15 Most health care is provided in the community, where collection of population data is the exception. The role of FHSAs in needs assessment suggested by the NHS Management Executive would require the collection of accurate statistics from GP primary care. Further, there is considerable evidence that the outcome measures currently obtained from GPs--prescribing and referral data--show that the behaviour of the doctor, not the characteristics of the population, is the most influential variable deciding cost and quantity of drugs or the number of referrals. 16 Recent assessment of the care provided to people with chronic renal failure suggests that a major reason for early death was late referral.17 The switch of emphasis from disease intervention to anticipatory primary care in the new GP contract requires the use of accurate databases and sophisticated recall systems from which population data could be obtained. About 60% of practices are now computerised (personal communication Doll). There are some 40 different and mutually exclusive systems that provide basically similar facilities. Integration with FHSA and DHA computers will not be possible on a large scale until GP systems are standardised or at least all collect a common core of data and support an agreed data exchange protocol. Until then data transfer will continue to consume vast amounts of time and paper. The D o l l has this in hand ('Is IT happening out there', Conference 9th May 91). Population surveillance
The potential benefit to the population from a shift in emphasis of primary care to anticipatory and preventative services has been well and persuasively reviewed. 8,9 It has also recently been suggested that a population-based strategy for dealing with major problems such as hypertension has more effect on morbidity than a strategy of deviant detection and treatment.18 However, the difficulties of some screening/prevention programmes reaching their target population, the possible damage done to patients and the cost effectiveness of programmes have called into question many of the screening programmes used at
361
GPs and Public Health
present. 19,20,21 Effective case finding of hypertension by GPs surveying their populations is an effective way of countering the 'rule of halves' in areas where primary care is organised for population surveillance. 22 Solutions
Present evidence suggests therefore that population surveillance by well-organised general practitioners provides the right balance between screening and case finding, disease management and health promotion. Such a system will only become universal if RHAs hold FHSAs to account for delivering it. RHAs are in a position to insist that FHSAs work with their local public health departments to deliver such a system as a prime objective. The arguments for a single agency to deliver primary care are persuasive but have not carried the day in this reorganization. 23 By demanding the collection and sharing of the right information and by signing up DHAs and FHSAs to common objectives the R H A has an opportunity to create an integrated pattern of care for the population without the disruption of a reorganization. A number of possible models for such collaboration can be envisaged, ranging from paper agreements throughout to jointly funded collaboration such as that outlined in Figure 1. Near any given DHA boundary there are likely to be people whose GP is in another D H A and across the border there will be people whose GP practices are from within the DHA. These patients could be disadvantaged if two bordering DHAs had radically different purchasing policies. Such problems could only be brought to light if DHAs and FHSAs were required by the RHA to comment on boundary issues. The RHA is well placed to safeguard the interests of these patients. Quality of care FHSAs have responsibility for monitoring the quality of their contractor services. As part of this they are required to introduce audit into general practice by founding and funding Medical Audit Advisory Groups. The purpose is educational only. 24 FHSAs have further responsibilities in approving protocols prior to payment for health promotion clinics, approving GP Principals as being adequately trained to be paid for paediatric surveillance, obstetric care and minor surgery and for checking that the service provided fulfils the terms and conditions of service of GPs.
Regional Health Authority] Primary Care Unit I
I
pu~lic Z~th DoptI
Community Service Unit(s
PRIMARY CANE COORDINATING UNIT Local Medical Committee(s)
Figure 1 Flow chart, primary care coordinating unit
362
J.A.G.
Paris et al.
It seems clear that a rolling programme of practice development is needed within each FHSA to help GPs develop the systems and skills for population surveillance where this is necessary, both to help doctors meet targets and to improve the overall standards of anticipatory care. The Royal College of General Practitioners has already set out the principles required for peer assessment. 25 This could be offered by the FHSA as a service to its contractors, 70% of the cost being subsidised through the practice staff reimbursement scheme. Some health care evaluation may only be possible by following cohorts of identified patients through different patterns of care via their GPs. Success of such a programme would depend on an equitable quality of general practice. Health promotion
The provision of health promotion in general practice inevitably requires that the practice be able to identify the population served and at risk, and that it can and does audit the results of the service. Systematic development of Health Promotion will only take place if criteria for approval of health promotion clinics begin to include the presence of such basic practice aids as an age/sex register, fully summarised and sorted notes, effective recall systems, and a morbidity index of those conditions for which health promotion clinics are offered. Such criteria could be imposed progressively over a number of years to allow time for the necessary changes to take place. Such a system is already in place as a means of approving practices for GP vocational training. 26 Data from FHSAs and GPs
Data already obtainable from FHSAs are listed in Table III. GP data are already gathered by a number of dedicated practices as part of the Royal College of General Practitioners' (RCGP) weekly return service. 27 The FHSAs and DHAs in High Wycombe and East Dyfed are developing joint databases on their populations. The introduction of anticipatory and preventative care into the GP contract means that all GPs will have to develop information systems that will enable them to fulfil their terms of service and provide evidence of their activity to their FHSA. A lot of data, then, are already or are about to be available. General practitioners see 90% of their patients at least once every three years and are ideally placed to obtain data for health needs assessment.28 GPs could be asked to provide a small common data set to their FHSA on their patients every three years, obtained opportunistically or at special health promotion clinics. If the system develops it may be that the Doll will reconsider their decision not to reward GPs financially for providing opportunistic screening, perhaps by introducing a further high and low target payment for providing information on the health status of 90% or 70% of their population aged between 16 and 75 years every three years respectively. There are a number of options for such a programme varying from obtaining details of every patient contact, as is done for the weekly return service, to surveying a random sample of patients from the FHSA register. Table IV lists the diversity and potential use by health authorities of GP-derived data. Such a multitude of options is m part a product of the uncoordinated way in which data systems and computing have been developed in general practice and the varying priorities of the practitioners themselves. There is a danger of gathering too much data to be usable. A more
GPs and Public Health TableIlI
363
Data available from FHSAs
Data
Source
Population details Age/sex of all patients registered Address/numerator district/health auth Jarman deprivation score neighbourhood Mobility of population including where to and from Immunisation details--children Immunisation details--adults Cervical cytology status including non-eligible Services available Surgery times/type (appointment systems) Doctor's qualifications and special interests Maternity services Paediatric surveillance Family planning services Minor surgery available Services already provided New registration examination done Number and nature of Health Promotion Clinics including disease management Paediatric surveillance Minor surgery Family planning Maternity services provided Referrals (including outpatients X-rays and blood tests) Prescribing information GP's own assessment of the previous year
Register (c) Deduced from regn. details (c) Register (c) Details previous/subsequent FHSA; new regn/removals (c) Target assessment returns quarterly Item of service payments to GPs Target assessment returns quarterly List List List List List List
of of of of of of
Principals Principals Principals Principals* Principals* Principals*
Claims for fees Application for approval and clinic claims Patient register Fee claims Patient register Claim (6 weeks postnatal) Annual reports (June) Pact data (confidential to prescribing advisor) Annual report (June)
*The population not registered with a GP or practice offering these services will need provision from their health authority.
pragmatic alternative is a system that gathers a continuous flow of small amounts of accurate data which are progressively refined according to experience.
Confidentiality T h e recent passage of an order through the H o u s e of C o m m o n s has to s o m e extent facilitated the exchange of data between F H S A s and D H A s . z9 This has gone some way towards correcting the anomaly of D H A s being responsible for pro-active primary care screening and immunisation p r o g r a m m e s of people they have hitherto been unable to identify from the F H S A register.
J. A. G. Paris et al.
364 Table IV
Potential use of GP-derived data by Health Authorities
Assessment of the need for hospital and other services
Population structure Morbidity incidence and prevalence Hospital planning data, e.g. hip replacement, rheumatology clinics Waiting list management Special registers - physical disability Planning, location, spread and scale of future health service
Assessment of Primary Health services
Day-to-day morbidity in General Practice Quantity/quality of services delivered and required How services are delivered Relationship between GP and community care services Extent and effectiveness of anticipatory care Prescribing in General Practice Producton of a 'Health Index' by linking morbidity/mortality data with 'Jarmanised' population index
Investigation of interface between primary and secondary care for specific patient groups
The care of diabetics, hypertensives, stroke patients, the mentally ill, asthmatics Respite care for the elderly, the young chronic sick, the physically disabled and people with learning difficulties Hospital discharge planning e.g. Cancer Registry entries and communicable diseases
Verification of other registries/official notifications, etc.
However, such an extensive system of personal data collection makes confidentiality an issue of paramount importance. Data sets should be anonymous wherever possible. The Soundex system, used for H I V and A I D S notification, has demonstrated the potential for providing good epidemiological information without compromising patient confidentiality. 3o The use of date of birth and post code to identify clinically important i n f o r m a t i o n may be necessary but such information is not technically anonymous. Individual identity may sometimes be necessary where a patient needs to be placed on a special register, for example. It would be the responsibility of the public health physician to ensure that adequate mechanisms exist for the maintenance of patient confidentiality. Conclusions
Despite anomalies and contradictions the NHS reorganization provides an opportunity to develop and p r o m o t e coordinated preventative and anticipatory health care programmes throughout primary care. R H A s clearly now have a duty to develop strategies and programmes for the development of primary care which are delivered by coordinated action from D H A s and FHSAs.
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365
As this develops it is likely that the reorientation of needs assessment towards primary care can produce information of much m o r e use in planning secondary care than the present system. A major change of emphasis from secondary to primary care reinforces the central role of general practice within the NHS. I m p r o v i n g standards of care in this area m a y yield greater health benefits for the population than investment elsewhere.
References 1. HMSO (1990). National Health Service and Community Care Act, Ch 19. London: HMSO. 2. NHS Management Executive (1991). Integrating Primary and Secondary Care. London: HMSO. 3. Health Departments of Great Britain (1989). General Practice in the National Health Service, The 1990 Contract, The Government's Programme for Changes to GPs' Terms of Service and Remuneration @stein. London: HMSO. 4. Department of Health (1989). Terms of Service for Doctors in General Practice. London: HMSO. 5. British Medical Association (1989). Supplementary Report to a Special Conference of Representatives of Local Medical Committees on 27 April 1989. SC2A 1988/89. London: General Medical Services Committee. 6. British Medical Association (1990). Special Conference Report SC2 1989/90. London: General Medical Services Committee. 7. Department of Health (1991). Statement of Fees and Allowances for General Practitioners. London: HMSO. 8. Tudor Hart, J. (1988). A New Kind of Doctor. The General Practitioner's Part in the Health of the Community. London: Merlin Press. 9. Tudor Hart J. et al. (1991). Twenty five years of case finding and audit in a socially deprived community. B~itish Medical Journal, 302, 1509-15:3. 10. Department of Health (1990). Health Circular No. HC (88) 43, and EL (90) MB115. London: HMSO. 11. Medico-Political Digest (1991). Inner city GPs fail to reach targets. British Medical Journal, 302,475. 12. Department of Health and Social Services (1986). Report of Community Nursing Review Team. Neighbourhood Nursing; a Focus for Care. London: HMSO. 13, BMJ (1991). Editorial: General Practice Fund Holding. British Medical Journal, 301, 1288-1289. 14. College of Health (Annual publication). Guide to Hospital Waiting Lists. London: College of Health. 15. Government Statistics Service (Annual publication). Hospital In-patient Enquiry. London: OPCS. 16. Barnsley Family Practitioner Committee (1989). Prescribing Pilot Pro]e& Final Report. Barnsley: Barnsley FSHA. 17. Feest, T. G., Mistry, C. D., Grimes, D. S. & Mallick, N. P. (1990). Incidence of advanced chronic renal failure and the need for end stage renal replacement treatment. British Medical Journal, 301,897-900. 18. Rose, G. & Day, S. (1990). The population predicts the number of deviant individuals. British Medical Journal, 301, 1031-1034. 19. Yudkin, J. S., Forrest, R. D. & Jackson, C. (1990). Urine analysis for sugar and protein. British Medical Journal, 300, 1063-1064. 20. Mant, D. & Fowler, G. (1990). Urine analysis for glucose and protein: are the requirements of the new contract sensible? British Medical Journal, 300, 1053-1055. 21. Kinlay, S. & Keller, R. F. (1990). Effectiveness and hazards of case finding for high
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cholesterol concentration. British Medical Journal, 300, 1545-1547. 22. Holmen, J., Forsen, L., Hjort, P. F., Midthjell, K., Waaler H. Th. & Bjorndal, A. (1991). Detecting hypertension: screening versus case finding in Norway. British Medical Journal, 302, 219-222. 23. National Association of Health Authorities and Trusts (1991). N A H A T Briefing No 13. 24. Department of Health (1989). Audit in General Practice. Working Paper No 6: Working for Patients. London: HMSO. 25. Baker, R. (1988). Practice Assessment and Quality of Care, Occasional Paper No. 39. London: Royal College of General Practitioners. 26. Royal College of General Practitioners (1980). Criterion No. 7. Requirements for Training Practices in General Practice. London: Royal College of General Practitioners. 27. Royal College of General Practitioners, Birmingham Faculty Research Unit (published weekly from 1976). OPCS Monitor, The Registrar General's Weekly Return Service for England and Wales. London: HMSO. 28. Kadous, H. (1989). Opportunistic screening for hypertension. Practitioner, 233,225-226. 29. Department of Health (1990). Health Circular No. HC(FP) (90) 10. London: HMSO. 30. PHLS AIDS Centre (1991). The surveillance of HIV-1 infection and AIDS in England and Wales. Communicable Disease Report, 1, Review No. 5. London: HMSO.
(1992), 106,357-366
© The Society of Public Health, 1992
General Practitioners and Public Health J. A. G. Paris, MRCP, 1 A. P. Wakeman, MRCGP 1 and R. K. Griffiths, FFCM 2
7Registrars in Public Health Medicine, Institute of Public and Environmental Health, (Formerly Principals in General Practice, Birmingham Family Practitioner Committee), 2Director, Institute of Public and Environmental Health, Health Services Research Centre, The Medical School, University of Birmingham, Edgbaston, Birmingham B 15 27-1-
Family Health Service Authorities (FHSAs), since 1st April 1991, have been both 'managed', by the Regional Health Authority, and 'managing', their contractor services. Both situations are relatively new to them, their Region and the contractors. We examine the opportunities and potential problems of this major strategic change. These relate to: (i) the establishment of effective coordination between providers of primary care services; (2) the establishment of minimum basic standards of care and administration for GPs (based on those set for training practices by the Regional Advisors in General Practice); (3) the development and validation of a data collection system from General Practice which could be used to establish a morbidity database from general practice as a means of health needs assessment as well as for performance review. Introduction Family Health Service Authorities ( F H S A s ) and hence general practitioner services b e c a m e accountable to the Regional H e a l t h Authorities ( R H A s ) f r o m 1st April 1991.1 This presents an opportunity for setting specific regional targets in primary care based on assessment of the needs of the population and the quality of service provided. T h e joint role of F H S A s with District Health Authorities ( D H A s ) in needs assessment has b e e n emphasised by the N H S m a n a g e m e n t executive. 2 The 1990 G P contract places great emphasis on population surveillance 3,4 (see T a b l e I). F H S A s are responsible for monitoring claims m a d e for p a y m e n t for, and setting the protocols of, health p r o m o t i o n clinics and the audit of quality through newly created Medical Audit Advisory G r o u p s . This change, from administration of general practice through Family Practitioner C o m m i t t e e s (FPCs) directly supervised by the D e p a r t m e n t of H e a l t h ( D o l l ) , to m a n a g e m e n t of G P primary care services by F H S A s under the direction of Regional Health Authorities, has taken place in the face of considerable opposition from G P representatives. 5,6 In contrast the shift in emphasis, clinical and financial, f r o m disease intervention to population surveillance, reflected opinion within the profession and was, on the whole, welcomed.
Correspondence to: Dr J Paris.
358
J. A. G. Paris et al. Table I
Summary preventative tasks performed by GPs after 1st April 1990
Task
Age range (years)
Offer check up appt. all patients Offer check up visit Offer check up on new patients Health promotion clinics Paediatric surveillance lmmunisation of children Cervical cytology in target group
16-74 75 and above all ages all ages 0-5 0-5 25-64
Frequency
(C)ompulsory (V)oluntary
Triennial Annual Within 3 months
C C C
Agree protocol c FHSA Agree protocol c DHA
V V*
As per DHA protocol Every five years
Vt Vt
*Only doctors accepted onto paediatric surveillance list paid a fee. tTargets of 70% and 90% for immunisation and 50% and 80% for cervical cytology qualify for high and low payments respectively.
Problems
The G P contract
Crucial elements of the contract are voluntary so some general practitioners may choose not to participate, particularly because there are contradictions between the new contractual requirements and changes in the system of remuneration. For instance, the proportional shift of payments from allowances to lists could encourage the accumulation of large lists and good incomes despite the absence of the provision of important extra preventative services. The absence of a link between deprivation payments and standards of care removes the incentive to upgrade practices in areas of greatest need. The high target levels necessary for payments may dissuade some practices from continuing with or investing in immunisation and cervical cytology services. Health promotion and preventative care
The absence of cash limits for health promotion clinic payments in general practice has resulted in much new activity which has not as yet been validated. Amounts spent are likely to be large (£1.6 million for Birmingham 1991-92. Personal communication Birmingham F H S A ) . Table II lists the payments made to general practitioners from 1st April 1991 for preventative services. 7 The criteria for health promotion clinic approval, for the surveillance examinations of new patients, the elderly and the triennial check offered to 16-74-year-olds are decided locally under national guidelines. The objectives of these services are not clearly defined. Are they simply designed to raise the standard of detection of asymptomatic disease and life style problems with the provision of appropriate advice, as suggested in the introduction to the 1990 Contract? 3,4 Is there also the intention to introduce a more direct 'public health' role into primary care as envisaged by Tudor Hart? 8'9 If this is the case do R H A s have a strategic role in primary care, setting minimum standards, deciding health promotion targets and giving guidance on disease management and health promotion protocols?
359
GPs and Public Health
Table II
Preventative task payments to GPs from 1st January 1991
Task
Payment (£)
Offer check up appt. all patients Offer check up visit Offer check up on new patients Health Promotion clinics Immunisation of children: Diphtheria/tetanus 90% 70% 90% Polio/pertussis 70% Measles/mumps/rubella 90% 70% 90% Preschool booster 70% Total fees payable to GPs for complete immunisation Cervical cytology 80% 50%
None None 5.80
45.00 target target target target target target target target
600.00 200.00 600.00 200.00 600.00 200.00 600.00 200.00 2400.00
target target
2280.00 760.00
Unit of payment
Per patient seen in time Per clinic (8-10 people) Per 22 two-yr-olds/annum Per 22 two-yr-olds/annum Per 22 two-yr-olds/annum Per 22 two-yr-olds/annum Per 22 two-yr-olds/annum Per 22 two-yr-olds/annum Per 22 five-yr-olds/annum Per 22 five-yr-olds/annum For each cohort of 22 children age range 0-5 yrs Per 430 eligible women/annum Per 430 eligible women/annum
Whither the D H A c o m m u n i t y units?
There is a substantial overlap in service responsibilities of District Health Authority ( D H A ) Community Units and general practitioners. Both have responsibility for health promotion and disease prevention programmes. D H A s are required to pick up those patients requiring immunisations, cervical cytology, family planning and paediatric surveillance not provided for by GPs. Indeed they have been required by the D o l l not to cut Family Planning Services so as to provide choice (and duplication) in this field. 1° Do we also need a choice of health promoter, community nurse, etc.? Further, whereas general practitioners are accountable to F H S A s for immunisation and cervical cytology services and targets, the overall responsibility for both services still resides with the D H A s who account to R H A s . Thus the main providers of the programme are not directly accountable to the body responsible for its implementation. Recent data show that inner city doctors are finding it difficult to reach their targets. 11 The m o n e y that would have been paid to these doctors is lost to the health service and no additional funds are made available to D H A s responsible for buying an alternative service. Neighbourhood or list-centred primary care or both?
The organisation of primary care by neighbourhood was favoured by the Community Nursing review team. 12 Community services, run in parallel with the 'list' system of general practice (and hospital referrals), can cause discontent where practices straddle D H A boundaries. Personal choice of family doctor does not guarantee choice of service provider in or out of hospital. The presence of two denominators of primary care provision, the F H S A register and the D H A population, raises important issues now that both bodies have managerial functions.
360
J.A.G.
Paris et al.
Will the GP list or the DHA boundary decide who provides care? Many DHAs provide community services to patients outside their boundaries if they are on the list of their resident practices. Accurate needs assessment based on neighbourhoods will depend on close cooperation between DHAs, FHSAs and general practitioners. The presence of fund-holding practices adds an unpredictable variable for assessing both service need and finance availability for the local DHA from whose fund allocation the GP budget allocation will be drawn.13 The R H A must now take notice of these problems because it can propose to change the boundaries and hold all of the relevant authorities to account. Needs assessment data
The pressure on DHAs from cash limits, an ageing population and improving but expensive technology has placed great emphasis on population health needs assessment. The present system of population surveillance and health needs assessment is centred on secondary and tertiary care and depends largely on mortality and morbidity statistics from the Office of Population Census and Surveys (OPCS) and data obtained locally from hospital activity returns, waiting lists etc. 14,15 Most health care is provided in the community, where collection of population data is the exception. The role of FHSAs in needs assessment suggested by the NHS Management Executive would require the collection of accurate statistics from GP primary care. Further, there is considerable evidence that the outcome measures currently obtained from GPs--prescribing and referral data--show that the behaviour of the doctor, not the characteristics of the population, is the most influential variable deciding cost and quantity of drugs or the number of referrals. 16 Recent assessment of the care provided to people with chronic renal failure suggests that a major reason for early death was late referral.17 The switch of emphasis from disease intervention to anticipatory primary care in the new GP contract requires the use of accurate databases and sophisticated recall systems from which population data could be obtained. About 60% of practices are now computerised (personal communication Doll). There are some 40 different and mutually exclusive systems that provide basically similar facilities. Integration with FHSA and DHA computers will not be possible on a large scale until GP systems are standardised or at least all collect a common core of data and support an agreed data exchange protocol. Until then data transfer will continue to consume vast amounts of time and paper. The D o l l has this in hand ('Is IT happening out there', Conference 9th May 91). Population surveillance
The potential benefit to the population from a shift in emphasis of primary care to anticipatory and preventative services has been well and persuasively reviewed. 8,9 It has also recently been suggested that a population-based strategy for dealing with major problems such as hypertension has more effect on morbidity than a strategy of deviant detection and treatment.18 However, the difficulties of some screening/prevention programmes reaching their target population, the possible damage done to patients and the cost effectiveness of programmes have called into question many of the screening programmes used at
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present. 19,20,21 Effective case finding of hypertension by GPs surveying their populations is an effective way of countering the 'rule of halves' in areas where primary care is organised for population surveillance. 22 Solutions
Present evidence suggests therefore that population surveillance by well-organised general practitioners provides the right balance between screening and case finding, disease management and health promotion. Such a system will only become universal if RHAs hold FHSAs to account for delivering it. RHAs are in a position to insist that FHSAs work with their local public health departments to deliver such a system as a prime objective. The arguments for a single agency to deliver primary care are persuasive but have not carried the day in this reorganization. 23 By demanding the collection and sharing of the right information and by signing up DHAs and FHSAs to common objectives the R H A has an opportunity to create an integrated pattern of care for the population without the disruption of a reorganization. A number of possible models for such collaboration can be envisaged, ranging from paper agreements throughout to jointly funded collaboration such as that outlined in Figure 1. Near any given DHA boundary there are likely to be people whose GP is in another D H A and across the border there will be people whose GP practices are from within the DHA. These patients could be disadvantaged if two bordering DHAs had radically different purchasing policies. Such problems could only be brought to light if DHAs and FHSAs were required by the RHA to comment on boundary issues. The RHA is well placed to safeguard the interests of these patients. Quality of care FHSAs have responsibility for monitoring the quality of their contractor services. As part of this they are required to introduce audit into general practice by founding and funding Medical Audit Advisory Groups. The purpose is educational only. 24 FHSAs have further responsibilities in approving protocols prior to payment for health promotion clinics, approving GP Principals as being adequately trained to be paid for paediatric surveillance, obstetric care and minor surgery and for checking that the service provided fulfils the terms and conditions of service of GPs.
Regional Health Authority] Primary Care Unit I
I
pu~lic Z~th DoptI
Community Service Unit(s
PRIMARY CANE COORDINATING UNIT Local Medical Committee(s)
Figure 1 Flow chart, primary care coordinating unit
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It seems clear that a rolling programme of practice development is needed within each FHSA to help GPs develop the systems and skills for population surveillance where this is necessary, both to help doctors meet targets and to improve the overall standards of anticipatory care. The Royal College of General Practitioners has already set out the principles required for peer assessment. 25 This could be offered by the FHSA as a service to its contractors, 70% of the cost being subsidised through the practice staff reimbursement scheme. Some health care evaluation may only be possible by following cohorts of identified patients through different patterns of care via their GPs. Success of such a programme would depend on an equitable quality of general practice. Health promotion
The provision of health promotion in general practice inevitably requires that the practice be able to identify the population served and at risk, and that it can and does audit the results of the service. Systematic development of Health Promotion will only take place if criteria for approval of health promotion clinics begin to include the presence of such basic practice aids as an age/sex register, fully summarised and sorted notes, effective recall systems, and a morbidity index of those conditions for which health promotion clinics are offered. Such criteria could be imposed progressively over a number of years to allow time for the necessary changes to take place. Such a system is already in place as a means of approving practices for GP vocational training. 26 Data from FHSAs and GPs
Data already obtainable from FHSAs are listed in Table III. GP data are already gathered by a number of dedicated practices as part of the Royal College of General Practitioners' (RCGP) weekly return service. 27 The FHSAs and DHAs in High Wycombe and East Dyfed are developing joint databases on their populations. The introduction of anticipatory and preventative care into the GP contract means that all GPs will have to develop information systems that will enable them to fulfil their terms of service and provide evidence of their activity to their FHSA. A lot of data, then, are already or are about to be available. General practitioners see 90% of their patients at least once every three years and are ideally placed to obtain data for health needs assessment.28 GPs could be asked to provide a small common data set to their FHSA on their patients every three years, obtained opportunistically or at special health promotion clinics. If the system develops it may be that the Doll will reconsider their decision not to reward GPs financially for providing opportunistic screening, perhaps by introducing a further high and low target payment for providing information on the health status of 90% or 70% of their population aged between 16 and 75 years every three years respectively. There are a number of options for such a programme varying from obtaining details of every patient contact, as is done for the weekly return service, to surveying a random sample of patients from the FHSA register. Table IV lists the diversity and potential use by health authorities of GP-derived data. Such a multitude of options is m part a product of the uncoordinated way in which data systems and computing have been developed in general practice and the varying priorities of the practitioners themselves. There is a danger of gathering too much data to be usable. A more
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Data available from FHSAs
Data
Source
Population details Age/sex of all patients registered Address/numerator district/health auth Jarman deprivation score neighbourhood Mobility of population including where to and from Immunisation details--children Immunisation details--adults Cervical cytology status including non-eligible Services available Surgery times/type (appointment systems) Doctor's qualifications and special interests Maternity services Paediatric surveillance Family planning services Minor surgery available Services already provided New registration examination done Number and nature of Health Promotion Clinics including disease management Paediatric surveillance Minor surgery Family planning Maternity services provided Referrals (including outpatients X-rays and blood tests) Prescribing information GP's own assessment of the previous year
Register (c) Deduced from regn. details (c) Register (c) Details previous/subsequent FHSA; new regn/removals (c) Target assessment returns quarterly Item of service payments to GPs Target assessment returns quarterly List List List List List List
of of of of of of
Principals Principals Principals Principals* Principals* Principals*
Claims for fees Application for approval and clinic claims Patient register Fee claims Patient register Claim (6 weeks postnatal) Annual reports (June) Pact data (confidential to prescribing advisor) Annual report (June)
*The population not registered with a GP or practice offering these services will need provision from their health authority.
pragmatic alternative is a system that gathers a continuous flow of small amounts of accurate data which are progressively refined according to experience.
Confidentiality T h e recent passage of an order through the H o u s e of C o m m o n s has to s o m e extent facilitated the exchange of data between F H S A s and D H A s . z9 This has gone some way towards correcting the anomaly of D H A s being responsible for pro-active primary care screening and immunisation p r o g r a m m e s of people they have hitherto been unable to identify from the F H S A register.
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Potential use of GP-derived data by Health Authorities
Assessment of the need for hospital and other services
Population structure Morbidity incidence and prevalence Hospital planning data, e.g. hip replacement, rheumatology clinics Waiting list management Special registers - physical disability Planning, location, spread and scale of future health service
Assessment of Primary Health services
Day-to-day morbidity in General Practice Quantity/quality of services delivered and required How services are delivered Relationship between GP and community care services Extent and effectiveness of anticipatory care Prescribing in General Practice Producton of a 'Health Index' by linking morbidity/mortality data with 'Jarmanised' population index
Investigation of interface between primary and secondary care for specific patient groups
The care of diabetics, hypertensives, stroke patients, the mentally ill, asthmatics Respite care for the elderly, the young chronic sick, the physically disabled and people with learning difficulties Hospital discharge planning e.g. Cancer Registry entries and communicable diseases
Verification of other registries/official notifications, etc.
However, such an extensive system of personal data collection makes confidentiality an issue of paramount importance. Data sets should be anonymous wherever possible. The Soundex system, used for H I V and A I D S notification, has demonstrated the potential for providing good epidemiological information without compromising patient confidentiality. 3o The use of date of birth and post code to identify clinically important i n f o r m a t i o n may be necessary but such information is not technically anonymous. Individual identity may sometimes be necessary where a patient needs to be placed on a special register, for example. It would be the responsibility of the public health physician to ensure that adequate mechanisms exist for the maintenance of patient confidentiality. Conclusions
Despite anomalies and contradictions the NHS reorganization provides an opportunity to develop and p r o m o t e coordinated preventative and anticipatory health care programmes throughout primary care. R H A s clearly now have a duty to develop strategies and programmes for the development of primary care which are delivered by coordinated action from D H A s and FHSAs.
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As this develops it is likely that the reorientation of needs assessment towards primary care can produce information of much m o r e use in planning secondary care than the present system. A major change of emphasis from secondary to primary care reinforces the central role of general practice within the NHS. I m p r o v i n g standards of care in this area m a y yield greater health benefits for the population than investment elsewhere.
References 1. HMSO (1990). National Health Service and Community Care Act, Ch 19. London: HMSO. 2. NHS Management Executive (1991). Integrating Primary and Secondary Care. London: HMSO. 3. Health Departments of Great Britain (1989). General Practice in the National Health Service, The 1990 Contract, The Government's Programme for Changes to GPs' Terms of Service and Remuneration @stein. London: HMSO. 4. Department of Health (1989). Terms of Service for Doctors in General Practice. London: HMSO. 5. British Medical Association (1989). Supplementary Report to a Special Conference of Representatives of Local Medical Committees on 27 April 1989. SC2A 1988/89. London: General Medical Services Committee. 6. British Medical Association (1990). Special Conference Report SC2 1989/90. London: General Medical Services Committee. 7. Department of Health (1991). Statement of Fees and Allowances for General Practitioners. London: HMSO. 8. Tudor Hart, J. (1988). A New Kind of Doctor. The General Practitioner's Part in the Health of the Community. London: Merlin Press. 9. Tudor Hart J. et al. (1991). Twenty five years of case finding and audit in a socially deprived community. B~itish Medical Journal, 302, 1509-15:3. 10. Department of Health (1990). Health Circular No. HC (88) 43, and EL (90) MB115. London: HMSO. 11. Medico-Political Digest (1991). Inner city GPs fail to reach targets. British Medical Journal, 302,475. 12. Department of Health and Social Services (1986). Report of Community Nursing Review Team. Neighbourhood Nursing; a Focus for Care. London: HMSO. 13, BMJ (1991). Editorial: General Practice Fund Holding. British Medical Journal, 301, 1288-1289. 14. College of Health (Annual publication). Guide to Hospital Waiting Lists. London: College of Health. 15. Government Statistics Service (Annual publication). Hospital In-patient Enquiry. London: OPCS. 16. Barnsley Family Practitioner Committee (1989). Prescribing Pilot Pro]e& Final Report. Barnsley: Barnsley FSHA. 17. Feest, T. G., Mistry, C. D., Grimes, D. S. & Mallick, N. P. (1990). Incidence of advanced chronic renal failure and the need for end stage renal replacement treatment. British Medical Journal, 301,897-900. 18. Rose, G. & Day, S. (1990). The population predicts the number of deviant individuals. British Medical Journal, 301, 1031-1034. 19. Yudkin, J. S., Forrest, R. D. & Jackson, C. (1990). Urine analysis for sugar and protein. British Medical Journal, 300, 1063-1064. 20. Mant, D. & Fowler, G. (1990). Urine analysis for glucose and protein: are the requirements of the new contract sensible? British Medical Journal, 300, 1053-1055. 21. Kinlay, S. & Keller, R. F. (1990). Effectiveness and hazards of case finding for high
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cholesterol concentration. British Medical Journal, 300, 1545-1547. 22. Holmen, J., Forsen, L., Hjort, P. F., Midthjell, K., Waaler H. Th. & Bjorndal, A. (1991). Detecting hypertension: screening versus case finding in Norway. British Medical Journal, 302, 219-222. 23. National Association of Health Authorities and Trusts (1991). N A H A T Briefing No 13. 24. Department of Health (1989). Audit in General Practice. Working Paper No 6: Working for Patients. London: HMSO. 25. Baker, R. (1988). Practice Assessment and Quality of Care, Occasional Paper No. 39. London: Royal College of General Practitioners. 26. Royal College of General Practitioners (1980). Criterion No. 7. Requirements for Training Practices in General Practice. London: Royal College of General Practitioners. 27. Royal College of General Practitioners, Birmingham Faculty Research Unit (published weekly from 1976). OPCS Monitor, The Registrar General's Weekly Return Service for England and Wales. London: HMSO. 28. Kadous, H. (1989). Opportunistic screening for hypertension. Practitioner, 233,225-226. 29. Department of Health (1990). Health Circular No. HC(FP) (90) 10. London: HMSO. 30. PHLS AIDS Centre (1991). The surveillance of HIV-1 infection and AIDS in England and Wales. Communicable Disease Report, 1, Review No. 5. London: HMSO.
