รายงานการศึกษาดูงานปฐมภูมิ ประเทศอังกฤษ

1. Townhill Medical Practice, Caterham, Surrey,

2. The United Kingdom
• Population: 59 million
• Capitol: London
• Includes: England,
Northern Ireland,
Scotland and Wales
• Government:
Constitutional
Monarchy

3. Yorkshire and The Humber
Leeds Partnerships NHS Foundation
Trust East Midlands
NHSSheffield
Yorkshire Ambulance Service NHS University Hospitals of Leicester
Trust East Midlands Ambulance Service
NHS Leeds NHS Trust
Bradford & Airedale Teaching PCT NHS Leicester City
NHS Doncaster Lincolnshire Teaching PCT
NHS Nottingham City
Leicestershire Partnership NHS Trust
West Midlands London
Heart of England NHS Foundation Trust Kings College Hospital NHS
Walsall Integrated Learning Disability Foundation Trust
Service NHS Newham
NHS Wolverhampton City East London Foundation Trust
NHS South Birmingham Royal Free Hampstead NHS Trust
NHS Birmingham East & North NHS Lewisham
NHS Ealing
South West South East Coast
NHS Bristol Surrey & Borders Partnership
South Western Ambulance Service NHS NHS Trust
Trust
NHS Cornwall and Isles of Scilly NHS Hastings & Rother
NHS Gloucestershire East Kent Hospitals NHS Trust
NHS Plymouth
NHSSwindon NHS Eastern & Coastal Kent
SEC Ambulance Service Trust

4. Health System Overview
 National Health Service Act 1948—based on
Beverage Report and the belief in post-World War II
solidarity.
 British NHS: National Health Service, first
comprehensive, nationalized healthcare program.
 Highly centralize management and finance
 Patients choose their provider
 Providers can have public & private practices

5. Principle of the NHS
 NHS Founding principles
‒
‒
‒
‒ ‗Cradle to Grave‘

7. Secretary of State for Health
• By: Dr Vannaboon
Phag-Udom
• Secretary of State for Health • MBBS DRCOG MRCGP
Department of Health
–
• Department of Health
Strategic Health Authorities – NHS
• Strategic Health Authorities
Special Health –
Authorities
–
Primary Care Trust –
–
Primary Care Trust
• Special Health Authorities
NHS Trusts – Provides health services to the whole population and help
with decision making e.g. NICE, NHS Direct
• Primary Care Trust
–
Primary Care
Team ,
• NHS Trusts
– Provider bodies like Hospital Trust, Ambulance Trust,
Mental Health Trusts, Foundation Trust
• Primary Care Team
– Provides Healthcare in Primary care setting

9. - NHS
General Taxation
• 95%
National Insurance
& Prescription
co-payment
DOH • National
Insurance and Prescription co-
SHA
payment
PCT
• PCT 80%
NHS

11. Structure of UK Health Services

12. Primary Care Trusts
The center of the NHS, control 80% of the total NHS budget
• PCTs are responsible for:
– Assessing the health needs of the local community.
– Commissioning the right services, for instance from GP
practices, hospitals and dentists.
– Improving the overall health of their local communities.
– Ensuring access to services
– Monitor interaction of social and healthcare organizations.
– Annual assessment of GP practices in their area.
– Buy and monitor services
There are more than 300 PCTs covering all parts of England since
April 2002, which report directly to their local Strategic Health
Authority.

13. PCT --
•
•
•
•
–
–

14. PCT contracts
• With owner of the Surgery – ‗Partners‘
• Agreement on services to be provided and their
quality
• Up to the partners to provide the services however
they see fit
• Increasing competition from Private sector

15. Payment to the contract holder
• Global Sum
• Estimate per head to provide services, including staff
costs
• Enhanced services
• Extra work e.g. Travel immunisation and Minor surgery
• Quality payments
• Target based
• Premises

16. Quality payments

17. Health Services Workforce
More than 1 million employees, largest single
employer in Europe
• MD‘s: 2.1 per 1000 pop (low #) (OECD 2002)
• General Practitioners (GPs): 60%
• GPs handle 90% of episodic care; gatekeepers
• GPs paid by mix of capitation, salary, fees
• Specialists are hospital based, called
―Consultants.‖
• Specialists/Hospitalists are salaried
• All MD‘s can have public and private practices

18. How much do GPs earn
 Depends on how much work & on what contract
 Typical Partner earns £90,000 to £110,000 per
annum
 Salaried GP earns £75,000 to £85,000 per annum
 Locum GP earns £65 to £85 per hour
 More than NHS paid Hospital Consultants

19. Health Services Workforce
• Nurses largest group within NHS staff
• 40% of NHS budget
• Nurses are trained specialist (child, MH)
• Work closely with GPs in the community
• Hospital nurses, much dissatisfaction salaries,
working conditions, work load.
• Nursing shortage
• NHS is actively recruiting Indian, Spanish and
Philippine nurses to make up for shortages in
the field.

20. Nurses Training
• 3 year Diploma or 3 year Degree
• Seniority grading
1. Registered Nurses
2. Specialist practice qualification
3. Clinical Nurse Specialist
4. Nurse Practitioners
5. Nurse Consultant
• Pay depending upon grade

27. Townhill Medical Practice
•
• 15,000
• 5 partners (4/5 GPs
are GP trainers)
• 3 part-time GPs
• 3 GP trainees(GP registrars:
• 2 Nurse Practitioners
• 2 Practice Nurses
• 2 Healthcare assistants
• 1 Practice Manager (+ 1
Assistant Practice
Manager, 1 Finance
A Group Practice

28. • District Nurses
• Health Visitors
• Community Midwifes
• Palliative Care Nurses

29. • 8.00-
13.00, 14.00-18.00)
•
– GPs and NPs
– Flexible Clinics (
practice nurses)
•
– Antenatal Clinics
– Child Developmental
Clinics
– Child Immunization
Clinics

30. Visit the Surgery

31. ?

32. Touch Screen
for Self Registration
•
•
•

33. Electronic medical record (EMR)
Paperless
Confidentiality

34. Provide primary care by teams
Phone-in &welcome to see patients
10 minute consultation
Telephone encounter
Enhance patient responsibility
Minor operation
Home visit
Quality and infectious control
Comprehensive and coordinate

35. British National Formulary & eResources

36. Prescription and payment
•
• Co-payment: per drug items ~ £7.4/item

37. What if patient needs
medication?
 Prescription pads
 Exemption
 <16
 <19 and in full-time
education
 >60
 maternity
 Chronic medical
problems
 pre-payment
 War pension cert
 contraceptives
 Otherwise pay £7.40 per
item
 Then goes to any
chemists to ‗cash-in‘
script

38. Prescription charges
• As of April 2008 the prescription
charge for medicines is set at £7.40
Northern Ireland £6.85, Scotland £5
and Wales free
• GPs can prescribe a maximum three-
month supply of the medication
• Except from paying for:
– People over sixty
– Children under sixteen or under
nineteen if the child is still in full time
education
– Patients with certain medical conditions

39. • Allergic condition – hay fever etc
• Conjunctivitis
• Coughs and colds
• Diarrhea
• Fungal infections – thrush, athlete’s
foot etc
• Hay fever
• Indigestion
• Muscular aches and pains
Over-the-counter • Toothache and teething problem
• Acne
• Allergic rashes
• Constipation
• Cystitis
• Emergency contraception
• Hemorrhoids
• Head lice
• Mouth ulcers and cold sores
• Sore throat
• Warts
• Worm

40. Electronic or Letter
Continuing of data between sites

41. Quality and Outcome Framework (QOF)

42. In the Practice
Nurse Makes differential diagnosis & clinical
Practitioner management
Flexible
clinic INR clinic Travel clinic
Practice
Nurse Wound management Immunization
Smear clinic AMB ECG’s BP’s
Midwife ANC and PP

43. In the community
District Nurse Visit people: providing clinical care
for patients
Community staff nurses
Health Promote good health and prevent
Visitors illness in the community
School nurse
Specialist Palliative care
Nurse

44. NP

45. PN

46. Heath care
Assistant

48. Vaccine Clinic

49. ANC

51. Well baby clinic

52. Baby café'

53. My Surgery
 Elm Grove Medical
Centre
 1 doctor
 1 nurse
 3 receptionists
 1 deputy manager
 1 practice manager
 Serves 2,000
patients

54. Modern Health Centre
 Amersham Health
Centre
 6 doctors
 1 trainee (Registrar)
 1 nurse practitioner
 3 practice nurses
 8 receptionists
 1 practice manager
 1 computer manager
 1 records manager
 3 secretaries
 Serves 11,000
patients

55. Settings for care
Community Based
Hospital Based Specialist &
Specialist Led Primary Care Lead
Primary Care
GP / Practice
Nurse &
Others

56. Diabetes Service Model
Level One Level Two / Level Three Level Four
Primary Care Community Diabetes Team Secondary Care
GP Led GP & Specialist Led Consultant Led
Multidisciplinary
Routine Care Extended care in community settings Joint Specialist Clinics
undertaken Dietetics T1D Patient Education
with specialist
support by Podiatry Programmes
phone/email Patient Education Programmes Insulin initiation
Multi-disciplinary clinics Insulin Pump
Patients can Specialist clinics telephone/email
access advice by
phone/email advice
Dieticians, Podiatrists, DSNs and
Psychologist Inpatient assessment
GPs and practice and management
nurses training Insulin initiation
Training Support Development

57. Settings for Care (3)
Case review
e-mail / telephone / virtual clinic
Progression CKD support.
Anaemia Specialist clinic – including dietetic
Bone Disease support
Joint Kidney / Diabetes Poor Control e.g. BP > 150 despite 3
Services if nephrotic / anti-hypertensives
eGFR <30 Hyperkalaemia /
Preparation for ESRF Advice on use oral hypoglycaemics
Patient Education / Support
Blood Pressure treatment / Management of Risk factors
Use of RAS inhibitors
Microalbuminuria / eGFR Screening
More regular follow up enhanced screening eyes / feet
FBC / Renal Bone Disease

58. Newly Diagnosed Diabetes / Diabetes Screening
Diabetes suspected –
initial assessment
No diabetes but at
Diabetes confirmed Lifestyle advice
risk
Adults with DKA or ketones in urine, Adults under 30 All other adults –
HONK – URGENT blood glucose with signs/ initiate
referral to hospital >25mmol/l symptoms of management
specialist team URGENT referral Type 2 to within primary
to specialist specialist-led care
service for triage team for triage
Inpatient - Optimisation of blood glucose
insulin therapy control with oral therapies or
Criteria lifestyle changes
and initial
training
Optimisation of blood glucose
control with insulin or oral
therapies Primary Care / Community
Community / Specialist
Tailored education programmes
Secondary Care setting
Indicators of quality
numbers emergency admissions /
numbers (proportions) completing education
Estimated prevalence / prevalence on Register / Qoff Numbers with retinopathy

59. Rapid
Access
Health
Telephone
Professional
Advice
Education
Practice based Community Diabetes Community Insulin
joint clinical
Team starts
consultations
/ Diabetes Network
Community Patient
Nurse Education
support Patient
Participation

60. Who is Commissioning Telecare
• Social Care Providers
• Primary Care Trust
• District and Borough Councils
• Acute Hospital Trust
• National Health Service
• Department of Health
• Supporting People
• Registered Social Landlords
• Private Health Providers

61. Surrey Telecare Projects
• Hospital Discharge Project
• Wrist Care
• Passive Falls Monitoring
• Dementia Monitoring, Extra Care and Residential Care Homes
• Prescription Compliance & Dementia Monitoring
• Monitored Smoke Detectors
• COPD Project

64. The Patients‘ Council
Derek Cooper
Patients‘ Council Chairman
Making it Better for Patients

65. The Patients‘ Council
2009 - 2010, Another Eventful Year
Allyson Jenkins
Patients‘ Council Vice-Chairman
Making it Better for Patients

66. The Role of the Patients‘ Council
To be the voice of patients and the public
To be independent, supportive and challenging
To be involved in Trust activities
To contribute to the future direction of the Trust
NOT to be directly involved in the management
of the Trust

67. Patients‘ Council Activities
Trust Board Meetings
Management Briefing Meetings
Representation on Trust Core Groups
Representation on Consultation Groups
Representation on User Groups
Meeting Patients and Visitors at Trust Events

68. Presentations to the Council
Cancer Services
Protection of Vulnerable Adults
The Productive Ward
Improving Patient Care
Patient Reported Outcome Measures
Maternity Services
Stroke Prevention and Treatment
Real Time Patient Monitoring

69. Patients‘ Council Core Groups
Patient Experience Group
Infection Prevention & Control Taskforce
Privacy & Dignity Group
Productive Wards Group
Patient Environment Action Group
Equality, Diversity & Human Rights Group
Patient Information Group
Travel Plan Group

70. Our Working Philosophy
The Patients‘ Council
being a positive and constructive force within the
Hospital Trust
representing patients‘ views in shaping the future
development of the Trust and the Patient Experience
working together for the benefit of patients, visitors and
all those who use the services of the Trust
Making it Better for Patients