บริ�การิสาธาริณสข ปฐมภู�ม�

ปริะเทศอั�งกฤษ

Townhill Medical Practice, Caterham, เม�อัง Surrey, ปริะเทศอั�งกฤษ

The United Kingdom

• Population: 59 million• Capitol: London• Includes: England,

Northern Ireland, Scotland and Wales

• Government: Constitutional Monarchy

Yorkshire and The Humber

Leeds Partnerships NHS Foundation TrustNHSSheffieldYorkshire Ambulance Service NHS TrustNHS LeedsBradford & Airedale Teaching PCTNHS Doncaster

West Midlands

Heart of England NHS Foundation TrustWalsall Integrated Learning Disability ServiceNHS Wolverhampton CityNHS South BirminghamNHS Birmingham East & North

South East Coast

Surrey & Borders Partnership NHS TrustNHS Hastings & RotherEast Kent Hospitals NHS Trust

NHS Eastern & Coastal Kent SEC Ambulance Service Trust

London

Kings College Hospital NHS Foundation TrustNHS NewhamEast London Foundation TrustRoyal Free Hampstead NHS TrustNHS LewishamNHS Ealing

East Midlands

University Hospitals of LeicesterEast Midlands Ambulance Service NHS TrustNHS Leicester CityLincolnshire Teaching PCTNHS Nottingham CityLeicestershire Partnership NHS Trust

South West

NHS BristolSouth Western Ambulance Service NHS TrustNHS Cornwall and Isles of Scilly NHS GloucestershireNHS PlymouthNHSSwindon

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

Principle of the NHS

NHS Founding principles

‒ ตอบสนองความต�องการที่��ส�าค�ญและจำ�าเป็�นส�าหร�บที่�กคน

‒ ฟร� ณ จำ�ดที่��ม�ความต�องการที่��ส�าค�ญจำ�าเป็�น

‒ ต�!งอยู่#$บนพื้&!นฐานความต�องการที่��จำะได�ร�บการด#แลที่าง คล)น)กมากกว$าด#เร&�องความสามารถในการจำ$ายู่ได�

‒ ‘Cradle to Grave’

โคริงสริ�างหลั�กSecretary of State for Health

Department of Health

Strategic Health Authorities

Primary Care Trust

NHS Trusts

Primary Care Team

Special Health Authorities

• By: Dr Vannaboon Phag-Udom

• MBBS DRCOG MRCGP• Secretary of State for Health

– เป็�นน�กการเม&อง ก�าหนดนโยู่บายู่และงบป็ระมาณ• Department of Health

– เป็�นบ�คลากรของ NHS ให�การสน�บสน�นงบป็ระมาณ วางนโยู่บายู่ ส��งการ ด�าเน)นงานตามแนวที่างของร�ฐบาล

• Strategic Health Authorities– เป็�นต�วแที่นกระที่รวงสาธารณส�ข ม�หน�าที่��ต)ดตาม

ก�าก�บการบร)หารในพื้&!นที่��ที่��ร �บผิ)ดชอบให�ม�ป็ระส)ที่ธ)ภาพื้

– เป็�นต�วกลางในการช$วยู่เร)�มต�นงานนโยู่บายู่– วางแผินกลยู่�ที่ธ2ในเขตพื้&!นที่��ร�บผิ)ดชอบ– ป็ระเม)นความสามารถและจำ�ดการให�เก)ดผิลการป็ฏิ)บ�ต)

งานที่��ด�ของ Primary Care Trust• Special Health Authorities

– Provides health services to the whole population and help with decision making e.g. NICE, NHS Direct

• Primary Care Trust– ร�บผิ)ดชอบจำ�ดหาบร)การส�ขภาพื้ให�แก$ป็ระชากรในพื้&!นที่��

ตามล�กษณะภ#ม)ศาสตร2ป็ระมาณ 250,000 คนต$อกองที่�น

• NHS Trusts– Provider bodies like Hospital Trust, Ambulance Trust, Mental

Health Trusts, Foundation Trust• Primary Care Team

– Provides Healthcare in Primary care setting

งบปริะมาณ - NHS

• งบปริะมาณส�วนใหญ่� 95% มาจากเง�นภูาษ%

• งบเพิ่�'มเติ�มมาจาก National

Insurance and Prescription co-

payment

• PCT เป*นผู้��ดู�แลังบปริะมาณ 80%

ขอังงบปริะมาณ NHS ท�.งหมดู

General Taxation

DOH

SHA

PCT

National Insurance& Prescription

co-payment

Structure of UK Health Services

Primary Care TrustsThe 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.

PCT -- เป็�นที่�!งผิ#�ให�บร)การและผิ#�ซื้&!อบร)การ

• วางแผู้นแลัะท/าให�ปริะชาชนท%'อัยู่��ในความริ�บผู้�ดูชอับม%สขภูาพิ่ดู%ไดู�ริ�บบริ�การิติามจ/าเป*นท%'ติ�อังไดู�

• ปริะสานเพิ่�'อัให�เก�ดูความริ�วมม�อัก�บอังค3กริท�อังถิ่�'น • สน�บสนนให�เก�ดูการิพิ่�ฒนา• เป*นท�.งผู้��ให�บริ�การิแลัะผู้��ซื้�.อับริ�การิในอังค3กริเดู%ยู่ว

– ให�บริ�การิโดูยู่ติริง เช�น ผู้ดูงคริริภู3– ซื้�.อับริ�การิให�ส/าหริ�บปริะชาชนในพิ่�.นท%' เช�น GP’s

services, Secondary and Tertiary Care

• งบปริะมาณข7.นอัยู่��ก�บขนาดูขอังแติ�ลัะ PCT

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

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

Quality payments

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

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

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.

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

• อัยู่��ในเขติก7'งเม�อังขอังลัอันดูอัน• ผู้��ข7.นทะเบ%ยู่น 15,000 คน• 5 partners ห�นส�วน (4/5

GPs are GP trainers)• 3 part-time GPs• 3 GP trainees(GP

registrars:แพิ่ทยู่3ปริะจ/าบ�าน)• 2 Nurse Practitioners• 2 Practice Nurses• 2 Healthcare assistants• 1 Practice Manager (+ 1

Assistant Practice Manager, 1 Finance Administrator, 1 Finance Assistant)

• 3 Medical Secretaries, 17 Receptionist/ Administrators

Townhill Medical Practice

A Group Practice

ท%มเจ�าหน�าท%'ในชมชน

• District Nurses

• Health Visitors

• Community Midwifes

• Palliative Care Nurses

เวลัาให�บริ�การิ

• จ�นทริ3 ถิ่7ง ศกริ3 (8.00-13.00, 14.00-18.00)

• คลั�น�กท%'ให�บริ�การิปริะจ/าทกว�น– GPs and NPs – Flexible Clinics ( โดูยู่

practice nurses)• คลั�น�กท%'ให�บริ�การิริายู่ส�ปดูาห3

– Antenatal Clinics– Child Developmental Clinics– Child Immunization Clinics– INR (Warfarin) Clinics– Travel Clinics– Women’s Health Clinics– Minor Surgery

Visit the Surgery

ม%อัะไริบ�างในหน�วยู่บริ�การิปฐมภู�ม�?

ริะบบน�ดู

ริะบบข�อัม�ลั

การิให�บริ�การิสขภูาพิ่

การิจ�ายู่ยู่าแลัะการิเก8บเง�น

ริะบบส�งติ�อั

การิบริ�หาริจ�ดูการิ

การิปริะเม�นคณภูาพิ่บริ�การิ

ริะบบน�ดู

• ติ�อังน�ดูลั�วงหน�าก�อันจะมาใช�บริ�การิไดู�ทกกริณ%• ลัดูริะยู่ะเวลัาการิริอัคอัยู่• ลัดูความเคริ%ยู่ดูจากการิท/างาน• เพิ่�'มความพิ่7งพิ่อัใจให�ก�บผู้��ป9วยู่

Touch Screen for Self Registration

ริะบบข�อัม�ลั

Electronic medical record (EMR)PaperlessConfidentiality

การิให�บริ�การิสขภูาพิ่

Provide primary care by teamsPhone-in &welcome to see patients10 minute consultationTelephone encounter Enhance patient responsibility Minor operationHome visitQuality and infectious controlComprehensive and coordinate

British National Formulary & eResources

ค��ม�อัการิใช�ยู่า

Prescription and payment

• จ/าเป*นติ�อังม%ใบส�'งยู่าจ7งสามาริถิ่ริ�บยู่าไดู�• Co-payment: per drug items ~ £7.4/item• Repeat prescription system

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

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– Those with low incomes

ยู่าท%'ปริะชาชนสามาริถิ่ซื้�.อัไดู�เอังจากริ�านขายู่ยู่า

• Allergic condition – hay fever etc• Conjunctivitis• Coughs and colds• Diarrhea• Fungal infections – thrush, athlete’s

foot etc• Hay fever• Indigestion• Muscular aches and pains• Toothache and teething problem• Acne• Allergic rashes• Constipation• Cystitis• Emergency contraception• Hemorrhoids• Head lice• Mouth ulcers and cold sores• Sore throat• Warts• Worm

Over-the-counter

ริะบบส�งติ�อัElectronic or Letter

Continuing of data between sites (ส�งติ�อัแลัะติอับกลั�บสม/'าเสมอั)

Quality and Outcome Framework (QOF)

In the Practice

Nurse Practitioner

Makes differential diagnosis & clinical management

Practice Nurse

Flexible clinic INR clinic Travel clinic

Wound management Immunization

Smear clinic AMB ECG’s BP’s

Midwife ANC and PP

Palliative care

In the community

District Nurse

Health Visitors

Specialist Nurse

Community staff nurses

Visit people: providing clinical care for patients

School nurse

Promote good health and prevent illness in the community

ระบบร)การ พื้ยู่าบาลNP

ระบบร)การ ของ PN

ระบบร)การ Heath care Assistant

ระบบร)การ เจำาะเล&อดส$งตรวจำ

Vaccine Clinic

ANC

Well baby clinic

Baby café'

My Surgery Elm Grove Medical

Centre1 doctor1 nurse3 receptionists1 deputy manager1 practice manager

Serves 2,000 patients

Modern Health Centre Amersham Health

Centre6 doctors1 trainee (Registrar)1 nurse practitioner3 practice nurses8 receptionists1 practice manager1 computer manager1 records manager3 secretaries

Serves 11,000 patients

Settings for care

Hospital Based Specialist Led

Hospital Based Specialist Led

Primary CareGP / Practice

Nurse & Others

Community BasedSpecialist &

Primary Care Lead

Diabetes Service Model

Level OnePrimary Care

GP Led

Level Two / Level Three

Community Diabetes TeamGP & Specialist Led

Multidisciplinary

Level FourSecondary CareConsultant Led

Routine Care undertakenwith specialist support by phone/email

Patients can access advice by phone/email

GPs and practice nurses training

Extended care in community settingsDieteticsPodiatry

Patient Education ProgrammesMulti-disciplinary clinics

Specialist clinics

Dieticians, Podiatrists, DSNs and Psychologist

Insulin initiation

Joint Specialist Clinics T1D Patient Education ProgrammesInsulin initiation Insulin Pumptelephone/email advice Inpatient assessment and management

Training Support Development

Progression CKD Anaemia

Bone DiseaseJoint Kidney / Diabetes Services if nephrotic /

eGFR <30 Preparation for ESRF

Case review e-mail / telephone / virtual clinic

support.Specialist clinic – including dietetic

supportPoor Control e.g. BP > 150 despite 3

anti-hypertensivesHyperkalaemia /

Advice on use oral hypoglycaemics

Patient Education / SupportBlood Pressure treatment / Management of Risk factors

Use of RAS inhibitorsMicroalbuminuria / eGFR Screening

More regular follow up enhanced screening eyes / feetFBC / Renal Bone Disease

Settings for Care (3)

Newly Diagnosed Diabetes / Diabetes Screening

No diabetes but at risk

Primary Care / Community

Secondary Care setting

Diabetes confirmed

Optimisation of blood glucose control with insulin or oral

therapies

Tailored education programmes

Inpatient - insulin therapy

and initial training

Adults with DKA or HONK – URGENT referral to hospital

specialist team

Diabetes suspected – initial assessment

Lifestyle advice

Adults under 30 with signs/

symptoms of Type 2 to

specialist-led team for triage

Community / Specialist

ketones in urine, blood glucose

>25mmol/l URGENT referral

to specialist service for triage

All other adults – initiate

management within primary

care

Criteria

Optimisation of blood glucose control with oral therapies or

lifestyle changes

Indicators of quality numbers emergency admissions / numbers (proportions) completing educationEstimated prevalence / prevalence on Register / Qoff Numbers with retinopathy

Community Diabetes Team

/ Diabetes Network

Rapid Access

Practice based joint clinical consultations

Community Insulin starts

Health Professional Education

Community Nurse support

Patient Education

Telephone Advice

Patient

Participation

Running Diabetes

Clinics in Some

Practices

Governance /

Practice Assessm

ent

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

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

The Patients’ Council

Derek CooperPatients’ Council Chairman

Making it Better for Patients

The Patients’ Council

2009 - 2010, Another Eventful Year

Allyson JenkinsPatients’ Council Vice-Chairman

Making it Better for Patients

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

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

Presentations to the Council

Cancer Services Protection of Vulnerable AdultsThe Productive WardImproving Patient CarePatient Reported Outcome MeasuresMaternity ServicesStroke Prevention and TreatmentReal Time Patient Monitoring

Patients’ Council Core Groups

Patient Experience GroupInfection Prevention & Control TaskforcePrivacy & Dignity GroupProductive Wards GroupPatient Environment Action GroupEquality, Diversity & Human Rights GroupPatient Information GroupTravel Plan Group

Our Working PhilosophyThe 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