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 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
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
NOT ONLY Evidence-based medicine (QOF, SIGN) BUT ALSO Unconditional, personalised, continuity of care, provided for all patients, whatever problems they present.
Percentage differences from least deprived decile for mortality, comorbidity, consultations and funding 242 Standarised Mortality <75 years Physical Mental comorbidity 220 Consultations/1000 registered Funding/patient registered 194 187 178 173 171 161 156 155 148 148 146 139 134 127 125 123 120 120 116 116 115 115 114 113 107 107 105 102 105 101 102 110 100 100 100 100 100 106 1 most 2 3 4 5 6 7 8 9 10 most affluent deprived “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%”
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
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 of consultations in areas of high and low deprivation Annals of Family Medicine 2016;14:117-124
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.
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
RELATIONSHIPS ARE THE SILVER BULLETS OF GENERAL PRACTICE AND PRIMARY CARE
87 : 13 86 : 14 GATEKEEPING 85 : 15 84 : 16
THE SECRET OF GATEKEEPING THERE IS NO GATE (at least, to unscheduled care) ONLY A GATEWAY (that patients can go through at any time)
Number of emergency admissions (all specs, all ages, all stays) at GG&C sites, 1995/6 - 2014/15. Source: SMR01 data from J Gomez. 5) UCCP, intro of 4 hr 170,000 Counting A&E target, ↑ A&E GRI AAU consultants. 1) New GP Contract stays 160,000 6) Funding starts to 2) New Hospital Consultant transfer from general Contract practice → CH 3) Loss of GP incentive to do 150,000 services OOH work 4) Commencement of transfer 111 NHS24 140,000 of LHCC functions to CHP 130,000 GRI WI, 7) CHPs have RAH completely Intro of 120,000 GEMS replaced LHCCs AAUs LHCCs Co-op in NHS24 8) Council tax freeze (SW) GG 110,000 ↓ District 9) Change Fund Nurses 100,000 SEE : Report of 3 rd National Deep End Conference www.gla.ac.uk/deepend
Ubiquitous, endemic complexity The value of previous encounters Empathy and trust A “worried doctor” Setting the bar high Every patient matters BJGP, June 2015
SERIAL ENCOUNTERS BRIEF ENCOUNTERS
RELATIONSHIPS WITH PATIENTS Initially face to face, eventually side by side Julian Tudor Hart A NEW KIND OF DOCTOR
SCHEHEREZADE TELLING 1001 TALES
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. Payne R, Abel G, Guthrie B, Mercer SW. The impact of physical multimorbidity, mental health conditions and socioeconomic deprivation on unplanned admissions to hospital: a retrospective cohort study. CMAJ 185 (e-publication ahead of print): E221-E228, 2013, doi:10.1503/cmaj.121349
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
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
CARE PLUS: a whole-system approach Time, continuity, person centredness and self-management support Longer consultation System time with continuity System Support meetings Professional and structure for long person-centred Practitioner consultations Patient CD and written guide on mindfulness Patient Plus CBT guide Community activities recommended
CARE Plus prevents decline in QOL (EQ5-DL) 0.6 0.5 0.4 baseline 0.3 6-month 0.2 0.1 0 care+ usual care Effect size = 0.35
CARE Plus is very cost-effective Cost < £13,000 per QALY NICE currently supports a cost of £20,000 per QALY
I’VE JUST INVENTED A MACHINE THAT DOES THE WORK OF TWO MEN. UNFORTUNATELY, IT TAKES THREE MEN TO WORK IT SPIKE MILLIGAN
TOO MANY HUBS INCREASES THE TREATMENT BURDEN
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 (10 th November 2014)
Most people with any long term condition have multiple conditions in Scotland Heart failure 3 9 14 74 Stroke/TIA 6 14 18 62 Atrial fibrillation 7 13 16 65 Coronary heart disease 9 16 19 56 Painful condition 13 21 21 46 Diabetes 14 20 19 47 COPD 18 19 17 47 Hypertension 22 24 19 35 Cancer 23 21 17 39 Epilepsy 31 23 16 29 Asthma 48 20 12 21 Dementia 5 13 18 64 Anxiety 7 17 20 56 Schizophrenia/bipolar 13 21 21 46 Depression 23 22 18 36 0% 20% 40% 60% 80% 100% 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 12 th May 2012
DEFINITIONS OF MUTLIMORBIDITY Two or more conditions 5+ conditions Combination of physical and mental health problems 242 Standarised Mortality <75 years Physical Mental comorbidity 220 Consultations/1000 registered Funding/patient registered 194 187 178 173 171 161 156 155 148 148 146 139 134 127 125 123 120 120 116 116 115 115 114 113 107 107 105 102 105 101 102 110 100 100 100 100 100 106 1 most 2 3 4 5 6 7 8 9 10 most affluent deprived
LINKS INVENTING THE WHEEL HUB SPOKES + RIMS Contact Keep Well Coverage Child Health Continuity Elderly Comprehensive Mental Health Coordinated Addictions Flexibility Community Care Relationships Secondary Care Trust Voluntary sector Leadership Local Communities INTEGRATED CARE DEPENDS ON MULTIPLE RELATIONSHIPS
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 of 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
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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