SILVER BULLETS LOOKING TO THE FUTURE OF GENERAL PRACTICE AND - - PowerPoint PPT Presentation

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SILVER BULLETS LOOKING TO THE FUTURE OF GENERAL PRACTICE AND - - PowerPoint PPT Presentation

Feb 19, 2023 35 likes •466 views

SILVER BULLETS LOOKING TO THE FUTURE OF GENERAL PRACTICE AND PRIMARY CARE Graham Watt Professor of General Practice University of Glasgow DEEP END REPORTS 1. First meeting at Erskine 2. Needs, demands and resources 3. Vulnerable families

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SILVER BULLETS LOOKING TO THE FUTURE OF GENERAL PRACTICE AND PRIMARY CARE Graham Watt Professor of General Practice University of Glasgow

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DEEP END REPORTS

1. First meeting at Erskine 2. Needs, demands and resources 3. Vulnerable families 4. Keep Well and ASSIGN 5. Single-handed practice 6. Patient encounters 7. GP training 8. Social prescribing 9. Learning Journey

  • 10. Care of the elderly
  • 11. Alcohol problems in young adults
  • 12. Caring for vulnerable children and families
  • 13. The Access Toolkit : views of Deep End GPs
  • 14. Reviewing progress in 2010 and plans for 2011
  • 15. Palliative care in the Deep End
  • 16. Austerity Report
  • 17. Detecting cancer early
  • 18. Integrated care
  • 19. Access to specialists
  • 20. What can NHS Scotland do to prevent and reduce heath inequalities
  • 21. GP experience of welfare reform in very deprived areas
  • 22. Mental health issues in the Deep End
  • 23. The contribution of general practice to improving the health of vulnerable children and families
  • 24. What are the CPD needs of GPs working in Deep End practices?
  • 25. Strengthening primary care partnership responses to the welfare reforms
  • 26. Generalist and specialist views of mental health issues in very deprived areas
  • 27. lmproving partnership working between general practices and financial advice services in Glasgow : one year on is

www.gla.ac.uk/deepend

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HEALTHY YEARS TOTAL LIFE IN POOR LIFE EXPECTANCY HEALTH EXPECTANCY years years years MENST 10% 76 5 81 RICHEST 10% 76 5 81 POOREST 10% 57 11 68 DIFFERENCE 19 6 13 WOMEN RICHEST 10% 78 6 84 POOREST 10% 61 15 76 DIFFERENCE 17 9 8

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NOT ONLY Evidence-based medicine (QOF, SIGN) BUT ALSO Unconditional, personalised, continuity of care, provided for all patients, whatever problems they present.

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Percentage differences from least deprived decile for mortality, comorbidity, consultations and funding

100 125 139 148 156 161 171 187 194 242 100 102 115 127 146 148 155 173 178 220 100 102 105 106 113 110 116 115 120 120 100 134 116 107 123 114 105 100 101 107 1 most affluent 2 3 4 5 6 7 8 9 10 most deprived Standarised Mortality <75 years Physical Mental comorbidity Consultations/1000 registered Funding/patient registered

“Over 2 million Scots in the most deprived 40% of the population received £10 less GP funding per head per annum than over 3 million Scots in the most affluent 60%”

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CONSULTATIONS IN DEPRIVED AREAS - 1

Multiple morbidity and social complexity Shortage of time Reduced expectations Lower enablement (especially for mental health problems) Practitioner stress

Mercer SM, Watt GCM Inverse care law : clinical primary care encounters in deprived and affluent areas of Scotland Annals of Family Medicine 2007;5:503-510

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CONSULTATIONS IN DEPRIVED AREAS - 2

Patients showed less desire for shared decision-making GPs perceived as less empathetic GPs displayed less patient-centred verbal and nonverbal behaviours Outcomes worse at 1 month (MYMOP) Perceived physician empathy predicted better outcomes

Mercer SW Higgins M Bikker AM Fitzpatrick B McConnachie A Lloyd SM Little P Watt GCM General practitioners’ empathy and health outcomes: a prospective observational study

  • f consultations in areas of high and low deprivation

Annals of Family Medicine 2016;14:117-124

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INVERSE CARE LAW

“The availability of good medical care tends to vary inversely with the need for it in the population served”. Julian Tudor Hart Not the difference between good and bad care, but between what general practices can do and could do with resources based on need.

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Applying the CARE measure and Patient Enablement Instrument (PEI) after general practice consultations

YOU CAN GET EMPATHY WITHOUT ENABLEMENT BUT YOU NEVER GET ENABLEMENT WITHOUT EMPATHY

Mercer SW Jani BD Maxwell M Wong SYS Watt GCM Patient enablement requires physician empathy: a cross-sectional study of general practice consultations in areas of high and low socio-economic deprivation in Scotland BMC Family Practice 2012, 13:6

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RELATIONSHIPS ARE THE SILVER BULLETS OF GENERAL PRACTICE AND PRIMARY CARE

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87 : 13 86 : 14 85 : 15 84 : 16

GATEKEEPING

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THE SECRET OF GATEKEEPING

THERE IS NO GATE (at least, to unscheduled care) ONLY A GATEWAY (that patients can go through at any time)

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100,000 110,000 120,000 130,000 140,000 150,000 160,000 170,000

GEMS Co-op in GG NHS24 1) New GP Contract 2) New Hospital Consultant Contract 3) Loss of GP incentive to do OOH work 4) Commencement of transfer

  • f LHCC functions to CHP

5) UCCP, intro of 4 hr A&E target, ↑A&E consultants. 6) Funding starts to transfer from general practice → CH services 7) CHPs have completely replaced LHCCs 8) Council tax freeze (SW) 9) ↓ District Nurses

WI, RAH GRI

Intro of AAUs

Counting GRI AAU stays 111 NHS24

LHCCs

Number of emergency admissions (all specs, all ages, all stays) at GG&C sites, 1995/6 - 2014/15. Source: SMR01 data from J Gomez. SEE : Report of 3rd National Deep End Conference www.gla.ac.uk/deepend Change Fund

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BJGP, June 2015 Ubiquitous, endemic complexity The value of previous encounters Empathy and trust A “worried doctor” Setting the bar high Every patient matters

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BRIEF ENCOUNTERS SERIAL ENCOUNTERS

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RELATIONSHIPS WITH PATIENTS Initially face to face, eventually side by side Julian Tudor Hart A NEW KIND OF DOCTOR

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SCHEHEREZADE TELLING 1001 TALES

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Payne R, Abel G, Guthrie B, Mercer SW. The impact of physical multimorbidity, mental health conditions and socioeconomic deprivation

  • n unplanned admissions to hospital: a retrospective cohort study.

CMAJ 185 (e-publication ahead of print): E221-E228, 2013, doi:10.1503/cmaj.121349

10% of patients with 4 or more conditions accounted for 34% of patients with unplanned admissions to hospital and 47% of patients with potentially preventable unplanned admissions.

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MEASURING OMISSION THE RULE OF HALVES 50% were diagnosed 50% were treated 50% were controlled i.e. 12% get best care THE IMPORTANCE OF GOOD INFORMATION

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Listen to the patient He is telling you the diagnosis

SIR WILIAM OSLER

Listen to the patient She is telling you her treatment goals

PROFESSOR JAN DE MAESENEER

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CARE PLUS: a whole-system approach

Time, continuity, person centredness and self-management support

Patient Practitioner System

System Professional Patient

Longer consultation time with continuity Support meetings and structure for long person-centred consultations CD and written guide

  • n mindfulness

Plus CBT guide Community activities recommended

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CARE Plus prevents decline in QOL (EQ5-DL)

0.1 0.2 0.3 0.4 0.5 0.6 care+ usual care baseline 6-month

Effect size = 0.35

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CARE Plus is very cost-effective Cost < £13,000 per QALY NICE currently supports a cost of £20,000 per QALY

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I’VE JUST INVENTED A MACHINE THAT DOES THE WORK OF TWO MEN. UNFORTUNATELY, IT TAKES THREE MEN TO WORK IT SPIKE MILLIGAN

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TOO MANY HUBS INCREASES THE TREATMENT BURDEN

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TREATMENT BURDEN

Patients and caregivers are often put under enormous demands by health care systems

Frances Mair, Carl May Thinking about the burden of treatment BMJ 2014;349:g6680 doi: 10.1136/bmj.g6680 (10th November 2014)

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Most people with any long term condition have multiple conditions in Scotland

23 13 7 5 48 31 23 22 18 14 13 9 7 6 3 22 21 17 13 20 23 21 24 19 20 21 16 13 14 9 18 21 20 18 12 16 17 19 17 19 21 19 16 18 14 36 46 56 64 21 29 39 35 47 47 46 56 65 62 74 0% 20% 40% 60% 80% 100% Depression Schizophrenia/bipolar Anxiety Dementia Asthma Epilepsy Cancer Hypertension COPD Diabetes Painful condition Coronary heart disease Atrial fibrillation Stroke/TIA Heart failure Percentage of patients with each condition who have other conditions This condition only This condition + 1 other + 2 others + 3 or more others

Karen Barnett, Stewart Mercer, Michael Norbury, Graham Watt Sally Wyke, Bruce Guthrie LANCET 12th May 2012

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DEFINITIONS OF MUTLIMORBIDITY Two or more conditions 5+ conditions Combination of physical and mental health problems

100 125 139 148 156 161 171 187 194 242 100 102 115 127 146 148 155 173 178 220 100 102 105 106 113 110 116 115 120 120 100 134 116 107 123 114 105 100 101 107 1 most affluent 2 3 4 5 6 7 8 9 10 most deprived Standarised Mortality <75 years Physical Mental comorbidity Consultations/1000 registered Funding/patient registered
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HUB Contact Coverage Continuity Comprehensive Coordinated Flexibility Relationships Trust Leadership SPOKES + RIMS Keep Well Child Health Elderly Mental Health Addictions Community Care Secondary Care Voluntary sector Local Communities

INVENTING THE WHEEL

INTEGRATED CARE DEPENDS ON MULTIPLE RELATIONSHIPS

LINKS

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MESSAGE FROM THE DEEP END Patients need referral services which are :- Local Quick Familiar Attached workers who will work flexibly and quickly according to the needs

  • f patients and practices

“your problem is our problem” A machine that does the work of two men but takes one person to work it Strengthening the generalist function

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Health practitioners need to ask not only “What do I do?” but also “What am I part of?” Don Berwick Head of US Medicare and Medicaid

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RESOURCE POOR PEOPLE RICH RESOURCE RICH PEOPLE POOR

LEADERSHIP OF HUMAN RESOURCES

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THE COLLABORATION LADDER Involving joint working between two potential partners 0 Never heard of each other 1 Have heard but have had no contact 2 Contact but no relationship 3 Relationship between named individuals 4 Joint review and planning

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A NEW BUILDING PROGRAMME FOR INTEGRATED CARE PATIENT STORIES LOCAL HEALTH SYSTEMS MACHINES THAT DO THE WORK OF TWO MEN

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BY POWERFUL BY CLEVER PEOPLE ? PEOPLE ? LEADERSHIP FOR INTEGRATED CARE BY STEETWISE BY THE PEOPLE ? PEOPLE ?

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BUILDING PRODUCTIVE LOCAL SYSTEMS CREATING A SOCIAL REVOLUTION IN HEALTH CARE

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SPOCK to KIRK : “It’s not logical, captain” LEARNING BY TRIAL AND ERROR

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A LEARNING ORGANISATION

“the best anywhere should become the “standard everywhere”

SHARING Knowledge Information Evidence Activity Experience Values

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