CHRONIC DISEASES MANAGEMENT, MULTIMORBIDITY, RESOURCES - - PowerPoint PPT Presentation

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)
• rganization, 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

LOMBARDIA

BOLOGNA

FIDENZA

SONDRIO MILANO

SWITZERLAND AUSTRIA FRANCE

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

• f 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!