Autism

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Autism What does Primary Care have to offer?
Dr Jamie Nicholls
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Dr Jamie Nicholls

• General Practitioner in Hockley, Essex
• Past Council member and Board member
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  of the National Autistic Society
• GP Tutor for Southend-on sea Postgraduate Centre

But above all father to
Andrew
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Andrew at 6 weeks, 1,11, 21 and 28years
...and now (hes the one with the cap)
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The two areas where Primary Care matters

• Diagnosis
• The rest of your life

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Development of Primary Care

• Pre 1980
• 1980 1997
• 1997-2004
• 2004-

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Pre 1980

• RCGP 1952
• General Practice failed specialist
• Vocational training
• MRCGP
• Postgraduate education voluntary

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1980 -1997

• Compulsory vocational training
• GP Speciality in its own right
• Purchaser / Provider split
• 1990 Fundholding
• PGEA
• Opportunity to encourage continuing medical
  education

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1997 - 2004

• Abolition of fundholding
• Establishment of Primary Care Organisations
• NICE

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1997 - 2004
Abolition of fundholding Establishment of Primary
Care Organisations NICE

• National Service Frameworks

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1997 - 2004
Abolition of fundholding Establishment of Primary
Care Organisations NICE
National Service Frameworks White Papers
Valuing People
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2001
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1999
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The vast majority of GPs (89) who did not know
how or where to refer a patient with suspected
autism also felt that the referral process in
their area was generally poor.
Four in ten (41) of GPs were not aware
of sources of local support and information.
Only a quarter (26) of GPs felt that a
final diagnosis of an autism spectrum disorder
was likely to be forthcoming within six months,
the timeframe identified in the forthcoming
National Autism Plan for Children. By contrast, a
third (33) felt that the diagnostic process was
likely to take over a year to complete.
82 of GPs told us that they have seen a
patient with a confirmed or suspected
autism spectrum disorder in the past 12 months.
When asked about referral pathways, more than one
in eight GPs (13) stated that they would not
know how and where to refer a patient with a
suspected autism spectrum disorder.
Four in ten (42) GPs told us that they did not
have sufficient information to make an
informed assessment about the likelihood of a
patient having an autism spectrum disorder.
Two-thirds (66) stated that the number
of patients with an autism spectrum disorder on
their lists has increased in the past five years.
Over a third (36) did not believe that the
referral process for autism in their area
operated smoothly and efficiently.
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2004 -

• The new GP Contract
• QOF targets

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2006
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But just in case you thought that this would
encompass all people with an autistic spectrum
disorder........

• it continues......

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2004 -

• The new GP Contract
• QOF targets
• Enhanced Services

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There are three types of enhanced service 2004
- Directed Enhanced Services (DES) - must be
provided by the PCT for its population, eg.
the childhood immunisations programme Local
Enhanced Services (LES) - locally developed
services designed to meet local health needs
National Enhanced Services (NES) - services
commissioned to meet local need to national
specifications and benchmark pricing. Other
examples of NES are enhanced care of the
homeless, more specialised services for multiple
sclerosis and specialised care of patients with
depression.
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The pre-requisites for taking part in the DES are
as follows practices will have liaised with
the LA to share and collate information, in order
to identify the people on their practice LD
register with moderate to severe learning
disabilities a practice providing this service
will be expected to have attended a
multi-professional education session (refer to
paragraphs 13 to 15 for further information). The
minimum expectation of staff attending will
include the lead general practitioner (GP), lead
practice nurse and practice manager/senior
receptionist. Practices may also wish to involve
specialist LD staff from the community learning
disability team to provide support and advice.
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• As a minimum, the health check should include
• a review of physical and mental health with
  referral through the usual practice routes.
• if health problems are identified
• - health promotion
• - chronic illness and systems enquiry
• - physical examination
• - epilepsy
• - behaviour and mental health
• specific syndrome check
• a check on the accuracy of prescribed
  medications
• a review of coordination arrangements with
  secondary care
• a review of transition arrangements where
  appropriate.

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2004 -

• The new GP Contract
• QOF targets
• Enhanced Services
• Practice Based Commissioning
• Payment by results

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Practice based commissioning Practice based
commissioning is about engaging practices and
other primary care professionals in the
commissioning of services Similar to
fundholding but the PCT holds the
chequebook PCT also has the power to approve how
any money is spent, and the emphasis is on the
directed areas (diabetes, CHD, cancer etc)
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Following referral from Primary Care, if the
secondary care provider considers that the case
will require more assessment than can be covered
by the standard PBR payment (e.g. DISCO
assessment) or a tertiary referral, they will
apply to the PCT for extra funding. The case for
funding will be referred to the PCT Special Cases
Review Panel The panel will seek further
information from the referring GP and secondary
care provider before making a decision to approve
or refuse funding. (Usually a lay
committee) First offer is usually refusal
then appeal process
9 months
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Education

• Pre 1990
• PGEA
• 2004 abolition of PGEA
• Sources of education for GPs

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Magazines periodicals freebies Pulse -
General Practitioner - Doctor - Practitioner -
Update Journals BMJ - RCGPJ - Lancet Online
BMJlearning - Doctors.net Lectures
symposia Self directed learning Specialist
resources NAS website - Researchautism.net
Books
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So where is this all heading?

• Education frozen revalidation still a long way
  off
• NICE report due 2011
• Government and PCT emphasis on their target
  areas- autism not even on the drawing board
• NHS employees burnt out by redisorganisation
• ......................problem recognised by Mencap

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The inquiry's recommendations include -
reasonable adjustments for people with a learning
disability by health services, including regular
health checks and liaison staff across services
- a confidential inquiry into the avoidable
deaths of people with a learning disability and a
permanent public health observatory to promote
good practice - compulsory learning disability
training for healthcare professionals - the
involvement of family carers in care and
treatment better inspection of how the NHS
treats people with a learning disability -
better data collection to identify people with a
learning disability. .but, like the Enhanced
Service no compulsion, no penalty for ignoring
it, and little reward.
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So where is this all heading?

• Education frozen revalidation still a long way
  off
• NICE report due 2011
• Government and PCT emphasis on their target
  areas - autism not even on the
  drawing board
• NHS employees burnt out by
  redisorganisation
• Development of polyclinics and Darzi Centres
• .......................and just in case you
  thought that
• matters
  could not get worse....

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Another redisorganisation
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Sorry it all seems so depressing...
...but it is