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McKenzie Lecture Prof Chris Salisbury 2018 - Coggle Diagram
McKenzie Lecture Prof Chris Salisbury 2018
16% of patients are on multiple QOF registers
Take up 30% of GP consultations
Complex Multimorbidity
What care do they need?
Treatment for simple illness same as everyone else
They also need Well organised pro-active chronic disease management
Needs patients to manage their own problems
Patients need an advocate in the system
Someone to help sort out the mess when things go wrong
Over next 20 years numbers will double
More than 1/3 will have dementia or depression or cognitive impairment
Example Person
5 co-morbidities attending 3 specialists 15 types of tablets a day
Things go wrong with the system all the time.
Letter cancelling then one asking why they didn't turn up, then taken off the list
2 different appointments for the same thing same day
Integrated care
What's been happening
Accessibility
People waiting more than a week to see GP increased from 13% in 2012 to 20% in 2017
Practices shut from 3.00pm at least one day a week
signs saying you can only talk about one problem at a time
Continuity of care/personal relationships
falling off a cliff none existant
Personal care
Dropping
Public Satisfaction dropping and overtaken by outpatient appointments
Number and Length of GP consultations has increased
16% increase in GP workload between 2007 - 2014
Investment in GP's 2005 to 2014 dropping (has gone up since then)
Numbers of GP's are leaving early
Impossible to do the job due to demands.
New things are chipping away at principles
focus on disease rather than patient centred care
Computerised check lists
Continuity of care is broken
48 hour access targets
Walk in centres
co-morbidity services
Electronic consultations with different unknown doctors
innovations not based on Principles lead to problems
Often promoted with Hype, commercial interests and no-evidence
Can cause harm or unintended consequences
e-consultations at least as likely to increase consultations as reduce it
Many people go to A&E with problems that can be seen by a GP
Numbers treated by GP's is vastly higher than A&E. If you put a GP in A&E and only 3% of people see this as a quicker way of getting treated we've just massively increased the load on A&E.
New models of care often more expensive than the GP practices
Consultation in a walk in center 50 % more expensive than a GP's
Like going to a fancy restaurant to save money on your supermarket bill
Supply induced demand
Telephone triage can lead to a 30% increase in demand.
Patients change their expectations according to options available
Segmenting diseases
Different specialist nurses managing different needs and gaps in care where they don't fit into the bucket or the generalist skills have been denuded
Don't assume care is broken into simple to treat packages.
Some people do have care that fits this usually young, fit that hardly ever go to the doctor.
More likely to go to the walk in centre
So putting lots of money into resources treating those with the least health needs draining resources from those with greater needs
If GP's are no longer the single entry point we confuse the system and people no longer understand it
People are confused about where to go so more in A&E with GP problems
If we lose generalism we won't have right patient right place right time, we'll have wrong care wrong place wrong time
If we lose GP's lists & clear accountablity between patient & doctore We'll end up with a great service & choice for people with simple problems and a second class safety net for the old, vulnerable, the ill
If continuity of care no longer relevant
We provide multiple points of access with fragmented services and greater choice with speedier access
But only works for people able to travel and ability to exercise choice
Will lead to longer waits for care, much higher costs, patients moving from GP's to A&E, better care for those with fewest health needs
What Patients Want
to know the doctor knows them as a person, knows about conditions, knows about local support services.
A single trusted point of liaison in the system who can advise them on the next steps and help cooridinate the care they need
General practice when working well does this.
Principles needed
Local
Generalist /comprehensive
Person centred, not disease centred
Gatekeeper route to all other services
Holding a central record about what is going on with this patient
Responsibility for a defined local population
Whether or not they turn up at the surgery
Housebound
Learning difficulties
Self neglect
Proactively seek these people
GP is an Expert generalist. Provider of holistic person centered care for undifferentiated illness across time with a continuous relationship
How do we fix
Don't mix up Conceptual failure (wrong idea) with implementation failure (good idea wrongly implemented)
Need specialists with GP's but not too many so they don't undermine continuity of care
Reactive vs Passive care
move from passive shopkeepers treating disease to active guardians of health care
Foodbanks as much as online retailers
Recognise what GP's job is (the principles) and make it easy to do it with a sustainable career structure
Turn into a telephone call center or warehouse for amazon and fewer will want to work there.
Initiatives that re-inforce the principles of GPs
Start with people with the greatest needs
How will it impact Mrs Smith, 80 year old, diabetes, early dementia and dodgy knees
Person centred care
Improve continuity
focus on quality of life
replace separate disease reviews with one 6 monthly whole person review
Longer consultations for these people
uk average = 9 mins, Sweden = 22 mins
innovate to improve access
Video, but make sure it reinforces rather than breaks continuity of care
As people get more information we need more help to understand this.
simplicity based on a single point of contact
As many services as possible from people in ONE PLACE, working in teams in one building with ONE record system with people who KNOW each other
you can't beat the importance of informal communication and one shared mission
Services which are small and local not large and impersonal
Still need federations but for back room functions, policies, quality control, education not to undermine personal relationships
DATA has to be shared
Sustainable careers for Doctors.
reduce stress.
Stop talking about portfolio careers.
New normal to be:- period of direct patient contact interspersed with teaching, research time to meet with colleagues and sharing . Not a portfolio careers
small percentage increase in funding would lead to huge improvement in GPs
promote, support and invest in comprehensive primary care.
Embrace innovatiions designed to support foundation principles of Accessibility, Generalism, Personal care, Coordination of Care for a Defined population
these are not wrong ideas, just not properly implemented
Half of those over 65 have multimorbidity