Downloaded from http://pmj.bmj.com/ on April 30, 2015 - Published by group.bmj.com
Editorial
Achieving better value: primary care must lead on population health Theodore Long,1,2 Ali M Khan,2,3 Nav Chana4 Whether in the USA or UK, the resounding question in the health sphere is: How do we achieve better value in healthcare? The answer to date has been simple: get bigger, merge administrative departments, get more managerialised, and so cut costs. But none of this represents real change: just some tinkering of the current hospital-centric system. In order to find a sustainable and effective solution, we must consider value and not cost while focusing on what contributes to better health. This means becoming serious about caring for people beyond a hospital’s walls. Population health, which links health outcomes for a population to the context of medical system and social determinants of health,1 offers the promise of dramatic improvement in value and personalisation for patients. This is not to diminish or downgrade the importance of continuing to improve healthcare for the individual, but rather to link that with an active approach to improving health. Doctors and other healthcare professionals will need to refocus their roles and renegotiate their relationships across the healthcare sector. Health systems across the globe are pressured to derive greater value in healthcare, which in the context of the continuing groundbreaking developments in medical technology must now centre on becoming serious about population health. The Institute for Healthcare Improvement’s triple aim sets out the laudable ambition for all health systems: improving the health of populations, enhancing the patient experience of care, and reducing the per capita cost of healthcare to ensure benefits can be applied across communities. It is the first of these, improving the health of the population, that is the most difficult and which seems out of the scope of healthcare. Delivering on this promise will not happen without clear leadership. 1
Robert Wood Johnson Clinical Scholars Program, Yale School of Medicine, New Haven, Connecticut, USA; 2 Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA; 3Iora Health, Boston, Massachusetts, USA; 4National Association of Primary Care, London, UK Correspondence to Dr Theodore Long, Robert Wood Johnson Clinical Scholars Program, 333 Cedar Street, SHM IE-61, PO Box 208088, New Haven, CT 06520, USA; [email protected]
Primary care—which assumes nearly 60% of all US patient visits and 90% of all those in the UK—is poised to take a lead role in this redefining of the aims of healthcare.2 The National Association of Primary Care in the UK already defines primary care as being much more than providing medical care.3 Primary care should deliver comprehensive care for all health and healthcare needs in the context of the community. We already know that robust primary care is associated with improvements in population health inequality and cost effectiveness.4 However, to truly improve population health means taking care of the entire denominator of a population. Then population-based primary care can target interventions to not only improve healthcare delivery, but also focus on the determinants of health that happen outside of doctors’ offices and hospitals. To do this, primary care must lead, but all others must take part. In the USA, this means a shift toward addressing social determinants of health— thinking about the social circumstances, environmental exposures, and behavioural patterns that can affect up to 60% of premature deaths.5 As new primary care delivery systems emerge, such as the patient-centred medical home (PCMH), there have been substantial reductions in emergency department use and hospital admissions when social vulnerabilities have been addressed concurrent with the provision of coordinated primary care.6 7 In vertically integrated delivery systems, which lend the current delivery system reform movement its philosophical underpinnings, primary care system redesign has more than paid for itself—as exemplified by the PCMH saving US$1.5 for every US $1 spent.8 An emerging financial case, then, further bolsters the shifting of resources away from where they have traditionally been spent in healthcare (medical care services, where 95% of the American healthcare dollar goes) toward population-based approaches (which historically saw but 5% of that aforementioned sum).5 For primary care, with its emphasis on systems thinking, multifactorial problem solving, and community engagement, this is a critical opportunity. However, changing this allocation of resources will require rethinking the goals of healthcare, with a shift from focusing on
Long T, et al. Postgrad Med J February 2015 Vol 91 No 1072
hospital care when patients become sick to prospectively investing in prevention. The UK has a strong history of primary care organised around general practice which takes comprehensive responsibility for a registered list of patients. International comparisons have shown that UK primary care compares favourably in relation to cost effectiveness, access and quality of care.9 Yet, notwithstanding this rich heritage, general practice in the UK has reached a crossroads. Over the last decade, the focus has shifted to demand-led, reactive healthcare provision facilitated by a ‘currency’ rewarding performance management against narrowly defined process outcomes. There is a growing need to develop care processes towards a more holistic population-based outcome approach. A key plank of the reorganisation of the National Health Service (NHS) by the Health and Social Care Act of 2012 was the reform of the landscape of commissioning secondary care and community services through the creation of Clinical Commissioning Groups (CCGs). The ambition was to bring commissioning decisions closer to the clinical teams committing resources, thus enabling the design of services around local populations. CCGs as membership organisations of general practices would be able to engage more effectively with clinicians and communities to improve population outcomes and reduce health inequalities. The reality has proven more challenging. In part, this is due to the innately bureaucratic and transactional culture that multiple reorganisations of the NHS have created. In spite of the system, in some areas, services truly integrated around patients and populations have emerged with greater alignment between health and social care. The future as set out in the NHS Five Year Forward View points to an urgent need for the development of new care models in which networks of provider organisations (organised horizontally as multispecialty community providers or vertically as primary and acute care systems) form the bedrock of provision going forward.10 The challenge is for CCGs to create an environment of collaboration between all providers, including primary and secondary care, where this makes sense for improving population health. This might mean, for example, that the responsibilities of a consultant respiratory physician would include not only caring for patients with respiratory disease attending their employing hospital, but also the respiratory health of the people in their locality. Thus a new style 59
Downloaded from http://pmj.bmj.com/ on April 30, 2015 - Published by group.bmj.com
Editorial of (collegial) leadership is called for to promote effective networking and federation, with perhaps less emphasis on the adversarial and competitive style of leadership. And yet, at the ground level, when we need most to hear the consolidated voice of primary care, we instead find a disturbingly high lack of engagement and provider burnout. In Europe, 65% of family doctors from 12 European countries scored highly for burnout.11 In the USA, even in the face of a looming shortage of up to 44 000 adult care generalists by 2025,12 nearly two-thirds of primary care internal medicine residents do not report an interest in going into primary care for their careers.13 And in the UK, despite the intention of CCGs to empower general practitioners to have a leadership role, nearly half of primary care physicians do not feel involved in CCG decision making.14 Frustrated by years of perceived underpayment and workload compression, primary care providers increasingly turn to alternative models of care (such as concierge or cash-only practice) or leave medicine altogether. Primary care will lead the way toward delivering the promise of better health for every population. But as evidenced by the problems of disengagement and burnout, this will not happen unless this is supported and understood by all. The whole of the healthcare community needs to listen and support the shift toward population health. Specialists will need to redefine their roles and responsibilities. They must support their primary care colleagues by understanding the importance of their potential contributions towards the health of the population. Policy makers for health and social care must work together to help address the social and environmental conditions that are
60
deeply linked to the health of the population. Primary care, positioned uniquely at the intersection of healthcare delivery and the social determinants of health, must shoulder the responsibility for leading this 21st century revolution. Building leadership in primary care cannot be accomplished overnight. It will require a meaningful investment in longitudinal training in leadership, health system design, and management. Physicians are traditionally trained to only look after individuals but not the health system. Strategies to cultivate leadership skills are being developed, and must continue to be advanced at the level of physician training15—but these rather sporadic efforts need to be made universal and accelerated. Through building these skills, primary care will be able to lead healthcare to ensure that our systems change perspective and, while continuing to develop and deliver good quality care to individuals, are designed to improve the health of the population. This is how to obtain better value and a healthier population.
Postgrad Med J 2015;91:59–60. doi:10.1136/postgradmedj-2015-133264
Twitter Follow Theodore Long at @tglong8
10
Contributors All authors listed have contributed sufficiently to the project to be included as authors, and all those who are qualified to be authors are listed in the author byline. TL accepts responsibility for the content of the manuscript.
11
Competing interests None. Provenance and peer review Commissioned; internally peer reviewed.
REFERENCES 1 2
3 4
5
6
7
8
9
12
13
14
To cite Long T, Khan AM, Chana N. Postgrad Med J 2015;91:59–60. Received 20 January 2015 Accepted 21 January 2015
15
Kindig D, Stoddart G. What is population health? Am J Public Health 2003;93:380–3. Cherry DK, Hing E, Woodwell DA, et al. National Ambulatory Medical Care Survey: 2006 summary. Natl Health Stat Report 2008;3:1–39. National Association of Primary Care. http://www. napc.co.uk (accessed 20 Jan 2015). Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q 2005;83:457–502. McGinnis JM, Williams-Russo P, Knickman JR. The case for more active policy attention to health promotion. Health Aff 2002;21:78–93. Economic Roundtable. Getting Home: Outcomes from Housing High Cost Homeless Hospital Patients. http://www.csh.org/wp-content/uploads/2013/09/ Getting_Home_2013.pdf (accessed 14 Jul 2014). O’Toole TP, Buckel L, Bourgault C, et al. Applying the chronic care model to homeless veterans: effect of a population approach to primary care on utilization and clinical outcomes. Am J Public Health 2010;100:2493–9. Reid RJ, Coleman K, Johnson EA, et al. The Group Health medical home at year two: cost savings, higher patient satisfaction, and less burnout for providers. Health Aff 2010;29:835–43. The Commonwealth Fund. Multinational Comparisons of Health Systems Data, 2013. http:// www.commonwealthfund.org/publications/ chartbooks/2014/multinational-comparisons (accessed 20 Jan 2015). National Health Service. Five Year Forward View. http://www.england.nhs.uk/wp-content/uploads/ 2014/10/5yfv-web.pdf (accessed 20 Jan 2015). Soler JK, Yaman H, Esteva M, et al. Burnout in European family doctors: the EGPRN study. Fam Pract 2008;25:245–65. Colwill JM, Cultice JM, Kruse RL. Will generalist physician supply meet demands of an increasing and aging population? Health Aff 2008;27:w232–41. West CP, Dupras DM. General medicine vs subspecialty career plans among internal medicine residents. JAMA 2012;308:2241–7. Health Service Journal. Fall in GP engagement with CCGs, NHS England survey finds. http://www.hsj.co. uk/news/commissioning/fall-in-gp-engagement-withccgs-nhs-england-survey-finds/5075901.article#. VFa5Hp_raKI (accessed 20 Jan 2015). Long T, Chaiyachati K, Khan A, et al. Expanding health policy and advocacy education for postgraduate trainees. J Grad Med Educ 2014;6:547–50.
Long T, et al. Postgrad Med J February 2015 Vol 91 No 1072
Downloaded from http://pmj.bmj.com/ on April 30, 2015 - Published by group.bmj.com
Achieving better value: primary care must lead on population health Theodore Long, Ali M Khan and Nav Chana Postgrad Med J 2015 91: 59-60 originally published online February 3, 2015
doi: 10.1136/postgradmedj-2015-133264 Updated information and services can be found at: http://pmj.bmj.com/content/91/1072/59
These include:
References Email alerting service
Topic Collections
This article cites 10 articles, 4 of which you can access for free at: http://pmj.bmj.com/content/91/1072/59#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Articles on similar topics can be found in the following collections General practice / family medicine (112) Health economics (11)
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
Editorial
Achieving better value: primary care must lead on population health Theodore Long,1,2 Ali M Khan,2,3 Nav Chana4 Whether in the USA or UK, the resounding question in the health sphere is: How do we achieve better value in healthcare? The answer to date has been simple: get bigger, merge administrative departments, get more managerialised, and so cut costs. But none of this represents real change: just some tinkering of the current hospital-centric system. In order to find a sustainable and effective solution, we must consider value and not cost while focusing on what contributes to better health. This means becoming serious about caring for people beyond a hospital’s walls. Population health, which links health outcomes for a population to the context of medical system and social determinants of health,1 offers the promise of dramatic improvement in value and personalisation for patients. This is not to diminish or downgrade the importance of continuing to improve healthcare for the individual, but rather to link that with an active approach to improving health. Doctors and other healthcare professionals will need to refocus their roles and renegotiate their relationships across the healthcare sector. Health systems across the globe are pressured to derive greater value in healthcare, which in the context of the continuing groundbreaking developments in medical technology must now centre on becoming serious about population health. The Institute for Healthcare Improvement’s triple aim sets out the laudable ambition for all health systems: improving the health of populations, enhancing the patient experience of care, and reducing the per capita cost of healthcare to ensure benefits can be applied across communities. It is the first of these, improving the health of the population, that is the most difficult and which seems out of the scope of healthcare. Delivering on this promise will not happen without clear leadership. 1
Robert Wood Johnson Clinical Scholars Program, Yale School of Medicine, New Haven, Connecticut, USA; 2 Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA; 3Iora Health, Boston, Massachusetts, USA; 4National Association of Primary Care, London, UK Correspondence to Dr Theodore Long, Robert Wood Johnson Clinical Scholars Program, 333 Cedar Street, SHM IE-61, PO Box 208088, New Haven, CT 06520, USA; [email protected]
Primary care—which assumes nearly 60% of all US patient visits and 90% of all those in the UK—is poised to take a lead role in this redefining of the aims of healthcare.2 The National Association of Primary Care in the UK already defines primary care as being much more than providing medical care.3 Primary care should deliver comprehensive care for all health and healthcare needs in the context of the community. We already know that robust primary care is associated with improvements in population health inequality and cost effectiveness.4 However, to truly improve population health means taking care of the entire denominator of a population. Then population-based primary care can target interventions to not only improve healthcare delivery, but also focus on the determinants of health that happen outside of doctors’ offices and hospitals. To do this, primary care must lead, but all others must take part. In the USA, this means a shift toward addressing social determinants of health— thinking about the social circumstances, environmental exposures, and behavioural patterns that can affect up to 60% of premature deaths.5 As new primary care delivery systems emerge, such as the patient-centred medical home (PCMH), there have been substantial reductions in emergency department use and hospital admissions when social vulnerabilities have been addressed concurrent with the provision of coordinated primary care.6 7 In vertically integrated delivery systems, which lend the current delivery system reform movement its philosophical underpinnings, primary care system redesign has more than paid for itself—as exemplified by the PCMH saving US$1.5 for every US $1 spent.8 An emerging financial case, then, further bolsters the shifting of resources away from where they have traditionally been spent in healthcare (medical care services, where 95% of the American healthcare dollar goes) toward population-based approaches (which historically saw but 5% of that aforementioned sum).5 For primary care, with its emphasis on systems thinking, multifactorial problem solving, and community engagement, this is a critical opportunity. However, changing this allocation of resources will require rethinking the goals of healthcare, with a shift from focusing on
Long T, et al. Postgrad Med J February 2015 Vol 91 No 1072
hospital care when patients become sick to prospectively investing in prevention. The UK has a strong history of primary care organised around general practice which takes comprehensive responsibility for a registered list of patients. International comparisons have shown that UK primary care compares favourably in relation to cost effectiveness, access and quality of care.9 Yet, notwithstanding this rich heritage, general practice in the UK has reached a crossroads. Over the last decade, the focus has shifted to demand-led, reactive healthcare provision facilitated by a ‘currency’ rewarding performance management against narrowly defined process outcomes. There is a growing need to develop care processes towards a more holistic population-based outcome approach. A key plank of the reorganisation of the National Health Service (NHS) by the Health and Social Care Act of 2012 was the reform of the landscape of commissioning secondary care and community services through the creation of Clinical Commissioning Groups (CCGs). The ambition was to bring commissioning decisions closer to the clinical teams committing resources, thus enabling the design of services around local populations. CCGs as membership organisations of general practices would be able to engage more effectively with clinicians and communities to improve population outcomes and reduce health inequalities. The reality has proven more challenging. In part, this is due to the innately bureaucratic and transactional culture that multiple reorganisations of the NHS have created. In spite of the system, in some areas, services truly integrated around patients and populations have emerged with greater alignment between health and social care. The future as set out in the NHS Five Year Forward View points to an urgent need for the development of new care models in which networks of provider organisations (organised horizontally as multispecialty community providers or vertically as primary and acute care systems) form the bedrock of provision going forward.10 The challenge is for CCGs to create an environment of collaboration between all providers, including primary and secondary care, where this makes sense for improving population health. This might mean, for example, that the responsibilities of a consultant respiratory physician would include not only caring for patients with respiratory disease attending their employing hospital, but also the respiratory health of the people in their locality. Thus a new style 59
Downloaded from http://pmj.bmj.com/ on April 30, 2015 - Published by group.bmj.com
Editorial of (collegial) leadership is called for to promote effective networking and federation, with perhaps less emphasis on the adversarial and competitive style of leadership. And yet, at the ground level, when we need most to hear the consolidated voice of primary care, we instead find a disturbingly high lack of engagement and provider burnout. In Europe, 65% of family doctors from 12 European countries scored highly for burnout.11 In the USA, even in the face of a looming shortage of up to 44 000 adult care generalists by 2025,12 nearly two-thirds of primary care internal medicine residents do not report an interest in going into primary care for their careers.13 And in the UK, despite the intention of CCGs to empower general practitioners to have a leadership role, nearly half of primary care physicians do not feel involved in CCG decision making.14 Frustrated by years of perceived underpayment and workload compression, primary care providers increasingly turn to alternative models of care (such as concierge or cash-only practice) or leave medicine altogether. Primary care will lead the way toward delivering the promise of better health for every population. But as evidenced by the problems of disengagement and burnout, this will not happen unless this is supported and understood by all. The whole of the healthcare community needs to listen and support the shift toward population health. Specialists will need to redefine their roles and responsibilities. They must support their primary care colleagues by understanding the importance of their potential contributions towards the health of the population. Policy makers for health and social care must work together to help address the social and environmental conditions that are
60
deeply linked to the health of the population. Primary care, positioned uniquely at the intersection of healthcare delivery and the social determinants of health, must shoulder the responsibility for leading this 21st century revolution. Building leadership in primary care cannot be accomplished overnight. It will require a meaningful investment in longitudinal training in leadership, health system design, and management. Physicians are traditionally trained to only look after individuals but not the health system. Strategies to cultivate leadership skills are being developed, and must continue to be advanced at the level of physician training15—but these rather sporadic efforts need to be made universal and accelerated. Through building these skills, primary care will be able to lead healthcare to ensure that our systems change perspective and, while continuing to develop and deliver good quality care to individuals, are designed to improve the health of the population. This is how to obtain better value and a healthier population.
Postgrad Med J 2015;91:59–60. doi:10.1136/postgradmedj-2015-133264
Twitter Follow Theodore Long at @tglong8
10
Contributors All authors listed have contributed sufficiently to the project to be included as authors, and all those who are qualified to be authors are listed in the author byline. TL accepts responsibility for the content of the manuscript.
11
Competing interests None. Provenance and peer review Commissioned; internally peer reviewed.
REFERENCES 1 2
3 4
5
6
7
8
9
12
13
14
To cite Long T, Khan AM, Chana N. Postgrad Med J 2015;91:59–60. Received 20 January 2015 Accepted 21 January 2015
15
Kindig D, Stoddart G. What is population health? Am J Public Health 2003;93:380–3. Cherry DK, Hing E, Woodwell DA, et al. National Ambulatory Medical Care Survey: 2006 summary. Natl Health Stat Report 2008;3:1–39. National Association of Primary Care. http://www. napc.co.uk (accessed 20 Jan 2015). Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q 2005;83:457–502. McGinnis JM, Williams-Russo P, Knickman JR. The case for more active policy attention to health promotion. Health Aff 2002;21:78–93. Economic Roundtable. Getting Home: Outcomes from Housing High Cost Homeless Hospital Patients. http://www.csh.org/wp-content/uploads/2013/09/ Getting_Home_2013.pdf (accessed 14 Jul 2014). O’Toole TP, Buckel L, Bourgault C, et al. Applying the chronic care model to homeless veterans: effect of a population approach to primary care on utilization and clinical outcomes. Am J Public Health 2010;100:2493–9. Reid RJ, Coleman K, Johnson EA, et al. The Group Health medical home at year two: cost savings, higher patient satisfaction, and less burnout for providers. Health Aff 2010;29:835–43. The Commonwealth Fund. Multinational Comparisons of Health Systems Data, 2013. http:// www.commonwealthfund.org/publications/ chartbooks/2014/multinational-comparisons (accessed 20 Jan 2015). National Health Service. Five Year Forward View. http://www.england.nhs.uk/wp-content/uploads/ 2014/10/5yfv-web.pdf (accessed 20 Jan 2015). Soler JK, Yaman H, Esteva M, et al. Burnout in European family doctors: the EGPRN study. Fam Pract 2008;25:245–65. Colwill JM, Cultice JM, Kruse RL. Will generalist physician supply meet demands of an increasing and aging population? Health Aff 2008;27:w232–41. West CP, Dupras DM. General medicine vs subspecialty career plans among internal medicine residents. JAMA 2012;308:2241–7. Health Service Journal. Fall in GP engagement with CCGs, NHS England survey finds. http://www.hsj.co. uk/news/commissioning/fall-in-gp-engagement-withccgs-nhs-england-survey-finds/5075901.article#. VFa5Hp_raKI (accessed 20 Jan 2015). Long T, Chaiyachati K, Khan A, et al. Expanding health policy and advocacy education for postgraduate trainees. J Grad Med Educ 2014;6:547–50.
Long T, et al. Postgrad Med J February 2015 Vol 91 No 1072
Downloaded from http://pmj.bmj.com/ on April 30, 2015 - Published by group.bmj.com
Achieving better value: primary care must lead on population health Theodore Long, Ali M Khan and Nav Chana Postgrad Med J 2015 91: 59-60 originally published online February 3, 2015
doi: 10.1136/postgradmedj-2015-133264 Updated information and services can be found at: http://pmj.bmj.com/content/91/1072/59
These include:
References Email alerting service
Topic Collections
This article cites 10 articles, 4 of which you can access for free at: http://pmj.bmj.com/content/91/1072/59#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Articles on similar topics can be found in the following collections General practice / family medicine (112) Health economics (11)
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
