Quality Symposium 2009

Key points to emerge from the Quality Symposium were:

(1) driving quality and patient safety systems requires good information systems, and

(2) Primary care has already made a substantive commitment to the quality agenda, and that will accelerate as a result of the symposium.

The presentations from both days at the Symposium are available here:

Quality Symposium presentations - Day one

Quality Symposium presentations - Day two

Auckland DHB chair Pat Snedden, who chairs the national Quality Improvement Committee, expressed optimism for achievement of the primary care quality agenda, given the information he had seen shared at the symposium, the quality and diversity of the people involved, the values expressed, the ethics of the profession, and the commitment to get the work done. QIC has already reported about the hospital-based system, and Mr Snedden had indicated before the symposium that QIC would refocus on primary care. “My challenge to you is to have everybody in the tent. I suspect this is the most difficult challenge, to include in its primary care narrative, community non-GP participants.”

Mr Snedden noted the “one heart many lives campaign” from Kaitaia is very clearly primary care at its most expansive, both clinically and culturally. “What stands it apart is that it is embracing of general practice but is not doctor-centric. Doctors still find it hard to make it part of their core practising paradigm. But I am optimistic. The inequalities analysis is now intuitive. This wider primary care understanding may become likewise intuitive in time.” Dr Fox immediately accepted the challenge. “As a College, RNZCGP feels that primary care is more than up to it. The College will play its part without impinging on the sovereignty of any other groups.”

Led by keynote presentations from Professor Barbara Starfield, from Johns Hopkins University in Baltimore and Dr Maureen Baker (UK), and with a team from the Royal Australian College of GPs, the more than 230 participants spanning general practices (managers, nurses and GPs), IPAs, PHOs and DHBs combined with Ministry of Health and others to hear there is robust evidence that investment in primary care is cost effective with quick response. “As a result, DHBs are to be encouraged to rebalance from the current focus on specialists and hospitals,” Dr Fox said. “Primary care orientation focuses on getting citizens the healthcare they need.”

Equally important was the Government’s role in education, workforce, practice support and remuneration. Good information systems are vital. To improve quality we need good evidence about what is actually happening, Dr Fox said. “We need agreed targets, good measurements, good – and safer – information systems. The electronic health record will reduce some current risks, but also creates new ones, so safety needs to be built into information systems from design through implementation. “This also requires collaboration between government and health care providers.”

Dr Fox said primary care has made a substantive commitment to the quality agenda and has accepted the need to take another step forward. “We need to focus on our agreed quality directions rather than our differences, and build on the excellent quality activities currently in place in primary care and elsewhere and find better ways to share and spread good practice.”

13 & 14 February 2009

Theme

The issue: Quality and Information

Greater general practice and primary care leadership is needed to improve quality and information systems in New Zealand

You are invited to attend the Annual RNZCGP Quality Symposium 2009. It provides an opportunity to participate in a discussion on current trends and emerging issues in general practice and primary care. The 2009 Symposium will continue to build on the outcomes of the 2008 Symposium and will highlight subsequent activity during the year.

Keynote speakers

The College is pleased to announce two eminent speakers. Together they have expertise in understanding of health care systems, primary care quality, clinical practice, patient safety, clinical risk management and systems.

(Primary care quality) Professor Barbara Starfield (US) is a physician and health services researcher at Johns Hopkins University, School of Population Health, and a commentator and leader in promoting the value of primary care.

(Information) Dr Maureen Baker CBE (UK), the National Clinical Leader for Patient Safety from the Office of the Chief Clinical Officer, in the National Health Service – Connecting for Health.  She is also the Honorary Secretary of the RCGP.

Professor Barbara Starfield (US)

A robust literature documents the importance of a strong primary care infrastructure in health systems. The benefits of strong primary care extend from greater effectiveness, greater efficiency (lower costs), and greater equity of health within populations. Strong primary care clinical services depend on supportive health policies in political jurisdictions—and constitute the operational aspect of primary HEALTH care. Policies that are critical in supporting primary care include distributing resources according to need rather than to market forces, Universal and progressive financing under the control or regulation of the government, no or low cost sharing for primary care, and a broad range of services (comprehensiveness) provided in primary care. The important clinical functions of primary care services are first contact when people have a new need or problem, person (not disease) focused care, a broad range of services available and delivered in primary care (rather than in specialty care (unless the need is too uncommon for the practitioner to maintain expertise), and coordination of care when people must go elsewhere for rare or unusual conditions.

Health systems with an excessive number of specialists suffer high costs, unnecessary care, and higher rates of adverse events. Although socio-demographic factors undoubtedly influence levels of health, a primary care oriented health system is a highly relevant policy strategy because its effect is clear and relatively rapid, particularly concerning the prevention of the progression of illness and the effect of injury, especially at younger ages.

Biography
Barbara Starfield, a physician and health services researcher, is a university distinguished professor and professor of health policy and pediatrics at Johns Hopkins University. She is internationally known for her work in primary care; her books, Primary Care: Concept, Evaluation, and Policy and Primary Care: Balancing Health Needs, Services, and Technology, are widely recognised as the seminal works in the field. She has been instrumental in leading projects to develop important methodological tools, including the Primary Care Assessment Tool, the CHIP tools (to assess adolescent and child health status), and the Johns Hopkins Adjusted Clinical Groups (ACGs) for assessment of diagnosed morbidity burdens reflecting degrees of co-morbidity. She was the co-founder and first president of the International Society for Equity in Health, a scientific organisation devoted to furthering knowledge about the determinants of inequity in health and ways to eliminate them. Her work thus focuses on quality of care, health status assessment, primary care evaluation, and equity in health. She is a member of the Institute of Medicine and has been on its governing council, and has been a member of the National Committee on Vital and Health Statistics and many other government and professional committees and groups. She has a BA from Swarthmore College, an MD from the State University of New York, Downstate Medical Center, and an MPH from Johns Hopkins University School of Public Health.

Pre-reading: http://bostonreview.net/BR30.6/starfield.html

Dr Maureen Baker CBE (UK)
National Clinical Lead for Patient Safety from the Office of the Chief Clinical Officer in the National Health Service – Connecting for Health.

The Office of the Chief Clinical Officer was formed in early 2007 to bring together the skills of clinicians working on the various programmes in the National Programme. The Office has been designed to strengthen clinical authority within the National Programme for IT, by ensuring that all programmes have the appropriate clinical input, are fit for purpose, and deliver real benefits for both the NHS and patients. 

The programme works to ensure:

•  That risk management and patient safety is embedded in every aspect of the Programme.
• Coordinates clinical and appropriate external input into the Programme’s activities and decisions.
• Ensures that NHS Connecting for Health programmes have suitable and adequate clinical input and provide a support mechanism for the continued professional development  of clinicians working on the Programme.
• Has overall responsibility for managing clinical risk.
• Develops and maintain relationships with key clinical, patient and public stakeholders.

http://www.connectingforhealth.hns.uk/engagement/clinical/occo/safety 

Maureen’s role focuses on risk management and the running and development of a training programme called ‘Awareness Training in Human Factors and Risk Assessment’. The training explores the principles of safety and risk within a national programme for IT.

In addition, her role looks at the potential of IT to help address known patient safety problems in the NHS.

Her particular interests are: emerging care, clinical governance and quality issues, and medical education.

The quality landscape in New Zealand

Progress made since the 2008 Symposium in Auckland, has been for the College to progress a Quality Agenda for general practice and for the GPLF to progress its qi4gp project. Clinical leadership and clinical governance are identified in each strategy as essential elements to enhance clinical practice and collaboration between primary care clinicians. Access to robust evidence and information is also identified by the qi4gp project as essential. Progress will be reported to the Symposium. The relevance of qi4gp and its contribution to other initiatives in the primary care sector is essential for increasing the primary care knowledge base and clinical capacity through interdisciplinary learning and multidisciplinary teamwork. As primary care develops, general practice clinicians have an increasingly important role to play in reducing disparities for patients.

There is growing realisation that preventive activity alone will not improve health outcomes for patients and we can learn from others. Barbara Starfield’s¹ article, ‘The primary care solution – Put doctors where they count’, highlighted the need for improvements in clinical management to achieve health gains for those with existing conditions. The New Zealand primary health sector has also identified barriers to progress due to current limitations of information systems.

In New Zealand primary care is almost always the first point of entry for those entering the health system. In 2006/2007 more than 80% of New Zealanders consulted a GP (3.2 million people) and on average three times during the year. By comparison, only two percent of this number (219,000 people) were admitted to public hospitals. On a daily basis, this presents an opportunity for clinical teams to improve clinical outcomes, reduce disparities, work with patients, their whanau, communities and populations, and coordinate care across primary, secondary, public health and disability services.

The points raised by Starfield2 provide direction for the way forward:

• the most practical approach to fix the health care system is to organise services around strengthened primary care and ensure everyone access’,
•  ‘a freely chosen primary care doctor is associated with better care, more appropriate health, and much lower health costs’.
• ‘To achieve this goal it is important to be more effective and efficient to be able to deliver primary care services’.
  

The recent Alma Ata Symposium in New Zealand³ this year also highlighted the need to facilitate collaboration between primary care and public health and in particular noted the importance of general practice as a key point of entry into the health system. With approximately 1135 general practices in New Zealand, they provide patients with a point of entry into primary care and to clinical teams who are able to work directly with them and their families/whanau. In addition 700 practices are enrolled in the RNZCGP CORNERSTONE General Practice Accreditation Programme. These practices and clinical teams are now in a unique position to influence improvements in managing health outcomes. They need robust quality and information systems to influence clinical management.    

RNZCGP Board of Quality

Dr John Wellingham (Chair)

Dr Jane Burrell

Dr Chris Fawcett

Dr Harry Pert

Dr Jim Vause

The Symposium will be of interest to general practitioners, other primary care clinicians, practice managers and administrators, those working in PHOs, DHBs, health sector policy and academics with an interest in quality. The College also welcomes people who use health services.

Please contact me if you have any questions about the Symposium. mgillon@rnzcgp.org.nz

Maureen Gillon, National Director Quality, RNZCGP

[1] Starfield B. The Primary Solution. Put doctors where they count.Boston Review.Nov/Dec 2005. http://www.bostonreview.net/BR30.6/starfield.html

[2] Starfield B. The Primary Solution. Put doctors where they count.Boston Review.Nov/Dec 2005. http://www.bostonreview.net/BR30.6/starfield.html

[3]http://www.ngangaru.co.nz/uploads/File/PHC%20Symposium.pdf 22/10/2008