CHRONIC DISEASES MANAGEMENT, MULTIMORBIDITY, RESOURCES LIMITATION/SPENDING REVIEW AND QUALITY IN ITALIAN GP/FM Dr. Gianluigi Passerini EQUIP
GENERAL PRACTICE IN THE NHS • 45,000 GPs (free contractors) • New Principals only if vacancies and V.T. • Capitation fee basis • Free choice of GP by patients • Maximum 1500 pts per GP
CONTINUITY OF CARE • Deputysing Service/Out of Hs (N.H.S.) • On duty at nights ( 8pm to 8 am), on Saturdays, Sundays and Bank Holidays • Doctors are different from GPs • Another Emergency Service (ambulance+E&A Dr+Nurse) is on duty 24/24 hours
CONTRACTS AND REGULATIONS • National Contract: general and overall regulations • Regional Contracts: according to local needs, issues and policies • Output: different (sometimes largly) organization, planning, tasks and funding
CHRONIC DISEASES AND MULTIMORBIDITY IN GP • Core content of Italian/European GP • Multitask and holystic approach • Continuity of systematic care • Efficiency • Cost/effectiveness • …vs hypermedicalization…
MULTIMORBIDITY PREVALENCE IN QUEBEC • 18-44 year old: 69% • 45-64 year old: 93% • >65 year old: 98% • N° of chronic conditions per multimorbidity patient: 2.8 (youngest) to 6.4 (oldest) • Ann Fam Med, 2005
MULTIMORBIDITY IN USA • 2000-> 60 Million • 2020-> 81 Million Mollica et al, 2007
CH DISEASES AND GP ROLE Example: A man, treated at a specialist clinic for heart failure, in the previous two years got there 54 times, for consultations, diagnostic tests and treatment. The equivalent of one day every two weeks was devoted to this “work”. May et al (BMJ 2009)
CHRONIC CARE IN N.H.S. • Announcements: must be based on GP/FM • Policies and funding: in favour of hospitals (only slight cuts, due to the limitation of resources and not to active planning) Public to private hospital ratio is about 50/50, with free choice by pts • Private hospitals paid by the N.H.S.
GPs ACCOUNTABILITY • Still a questionable issue • Wide variety of professionality and responsibility • …
GP WORKING STRUCTURE 1 • Group Practices (same premises) • Networks (different premises) • Staff (*) • Diagnostic opportunities (directly paid) • Self rented or owned premises (90%) (*) Mostly directly paid)
GP WORKING STRUCTURE 2 Ministry’s of Health aim: Aggregated models of GP, integrated with Deputysing Service doctors, specialists and basical diagnostic services. Regions: development of different models to approach chronic care
AUSTRIA SWITZERLAND SONDRIO FRANCE MILANO LOMBARDIA FIDENZA BOLOGNA
EMILIA-ROMAGNA • Case della Salute (Houses of Health) • Public premises • GPs Group Practices integrated with staff, Dep. Service doctors, diagnostic services and specialists • Staff etc in charge of the N.H.S. • Fee for service incentives for GPs
LOMBARDIA 1 C.RE.G. (Chronic Related Groups) • Auction for one (or+) years of overall comprehensive care 24/24 hours (including Call Centre) of large numbers of chronic patients (i.e. diabetes, ch. bronchitis, hypertension) according to protocols of care defined by the Region
LOMBARDIA 2 C.RE.G. (Chronic Related Groups) • GPs can participate only if in large aggregated organizations (cooperatives) • More affordable by hospitals and large private profit organizations • Only a few experimental ones already established • …?
CHRONIC DISEASES CLINICS IN HOSPITALS • Examples: diabetes, hypertension, arthropathies… • Overlapping with GPs to conquer new territories • Fighting vs abdication by GPs
SPENDING REVIEW IN THE NHS • The central government has reduced money transfer to Regions and stopped settling debts • Regional tickets have been set • Some cuts on hospitals (but still too many, so affecting GP funding) • Quality down? And waiting-lists up
SPENDING REVIEW IN GP • Vacancies not repalced • Payments reduction (10->20&) • Clinical governance programs cut • Strict control on drug and specialistic prescriptions (done by GPs, if in charge to N.H.S.)
LIMITATION OF RESOURCES AND QUALITY OF CARE • Still too many hospitals-> >hypermedicalization • Lack of clinical protocols and guidelines shared with specialists • Lack of quality control on individual GPs (and, of course, also on hospitals)
IN THE DISCUSSION… • We want to ask each of you how resources limitation is faced in your country (one problem and one answer). • We would like to list every idea and/or action taken anywhere in the enlarged Europe!
THANK YOU FOR COMING TO BOLOGNA!
Recommend
More recommend
