Priorities in prescribing

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Priorities in prescribing
Philip Leech Principal Medical Officer for
Primary Care, Department of Health
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• New configurations and new ways of thinking
• Quality
• Variation and integration
• Patient safety
• Information and Indicators
• GMS contract
• (and workload management)
• facilitation
• access to care

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• New configurations and new ways of thinking
• Quality
• Variation and integration
• Patient safety
• Information and Indicators
• GMS contract
• (and workload management)
• facilitation
• access to care

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KAISER SHIFT

• Maximise primary community settings
• Maximise prevention and chronic disease
  management programmes
• Maximise use of resources in the acute
  sector/reduction of length of stay/effective
  diagnostics

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DIVERSITY OF PROVISION
THIRD SECTOR
PRIVATE
Walk in Centres
Foundation hospitals
UK INDEPENDENT SECTOR
NHS ACUTE TRUSTS
GPS
OWNERSHIP
DTCs
PRIVATE
PUBLIC
FOCUS OF BUSINESS
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Simple Rules for the 21st Century Health Care
System
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Simple Rules for the 21st Century Health Care
System
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• New configurations and new ways of thinking
• Quality
• Variation and integration
• Patient safety
• Information and Indicators
• GMS contract
• (and workload management)
• facilitation
• access to care

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Talking treatments
Prescription drugs
Refer
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Referral
Talking treatments
Prescription drugs
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Improvement across the board? or Reduction in
variation?
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Improvement across the board? or Reduction in
variation?
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Pathways of Innovation
Innovation moves through the system by tolerance
to risk
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• New configurations and new ways of thinking
• Quality
• Variation and integration
• Patient safety
• Information and Indicators
• GMS contract
• (and workload management)
• facilitation
• access to care

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Why is there a need forfocus on quality in
healthcare?

• Variation in processes and outcomes of care are
  common
• The practice of healthcare too often lags behind
  the science of healthcare
• Patient safety has had too low a profile
• Tolerance of poor quality and poor practitioner
  performance has been too great
• Barriers between organisations and professional
  groups have often been too high
• Inequalities in access to appropriate care are a
  constant problem
• Innovation and good practice in one place are
  slow to permeate the whole system
• Patients have expectations as consumers in a
  modern society
• Information base for assessing and describing
  quality are not strong

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• REASONS FOR ERRORS
• Lack of knowledge/ information about the patient
• Lack of knowledge and information about the drug
  
• Calculation errors
• Illegible prescriptions
• Drug names that sound or look alike
• Confusion over dosage formulation
• Mis-interpretation of abbreviated drug names
• Misuse of zeros and decimal points
• Unusual routes of drug administration
• Uncommon or complicated dosage regimens
• Poor history taking
• Dispensing errors

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KEY SYSTEMS FAILURES IDENTIFIED IN THE TOFT REPORT

• a weak safety culture
• inadequate operational practices
• lack of explicit protocols
• no training
• communication failures
• poor technical design of medical equipment and
  packaging

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YOU MUST ASK OF YOUR ORGANISATION

• Are patient safety and quality key objectives for
  the organisation and considered by the Board?
• Do induction and development programmes include
  patient safety issues?
• What is being done to educate/inform the
  workforce about patient safety issues? 
• Can you demonstrate indisputably that your
  service is becoming safer for patients year in
  year out?
• Can the management and clinical teams show you
  examples of where through analysing something
  that has gone wrong, care of future patients will
  be much safer?

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YOU MUST ASK OF YOUR ORGANISATION

•  
• Is your organisation in regular contact or
  twinned with another organisation in a different
  sector in the UK or in health care
  internationally which has a reputation for
  excellence in safety? 
• What is your organisation doing to reduce the
  risk of medication error (which accounts for a
  quarter of all harm to patients)? 
• Pick the worst three errors you have heard of and
  ask managers and professional staff if they could
  happen in your organisation.
• If something serious happened would the culture
  of your organisation be to cover it up or learn
  from it?
• Are patients actively involved in activities to
  improve safety and reduce risk?

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• New configurations and new ways of thinking
• Quality
• Variation and integration
• Patient safety
• Information and Indicators
• GMS contract
• (and workload management)
• facilitation
• access to care

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• New configurations and new ways of thinking
• Quality
• Variation and integration
• Patient safety
• Information and Indicators
• GMS contract
• (and workload management)
• facilitation
• access to care

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• A view from the expert group
• Clinical care
• Practice organisation
• Patient experience
• Impact on general practice

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• Clinical indicators - 100-110 indicators
• - 9-11 conditions
• Potential for major improvement in care
• Reduction in morbidity and mortality
• Generally strong evidence base
• Exception reporting means clinically relevant

?
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• Organisational standards
• Derived from good practice standards - e.g.
  Quality team development, Practice accreditation
• Comprehensive coverage

?
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• Patient experience
• Developmental approach
• Cautious use of patient surveys
• Incentive to involve patients in discussion

?
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• Predicted impact of framework
• General practice more bio-medical
• More nurse led care
• Greatly improved chronic disease management
• Comprehensive computerisation
• Increase in specialisation within practices
• Better practice management
• Improvement in consumer orientation
• Possible loss of personal doctoring
• Possibly reduced quality for non-incentivised
  areas
• Possible loss of continuity and co-ordination
• Probable improvement in morale / recruitment etc
• Increased cost

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• New configurations and new ways of thinking
• Quality
• Incentives and integration
• Patient safety
• Information and Indicators
• GMS contract
• (and workload management)
• facilitation
• access to care

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Treatment rates for antidepressant medication
and cholesterol lowering with statins are both
lower than expected in the bottom quintile of the
distribution of socioeconomic status
Primary health care teams treat 100 of the
population.epidemiologists do not take this into
account in studies in deprived areashappy with a
60 return
There is an inadequate recognition of the
contributions that clinical services make to
public health and the extent to which corrections
of variations in service delivery might
contribute to public health gain
Graham Watt, Lancet july 20 2002
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Comorbidity in deprived areas comprises the
number, severity and complexity of health and
social problems that exist within families
Not only are such problems concentrated in
families, such families are concentrated within
practices and, in many parts of the country, such
practices are concentrated within areas
Yet, most evidence, guidelines, health technology
assessments, national service frameworks and
health policies are based on the assumption that
patients have single conditions
Graham Watt, Lancet july 20 2002
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