Engaging the primary care sector

Bruce Arroll Dept of General Practice and Primary Health Care and Action on Smoking and Health (ASH)Nov 2010

Structure- heart/smoking

• Overview of NZ health system• PHOs and where they sit• GPs what they can and cannot do, pressures

etc• What is possible with a population approach• Questions? • Connecting with GP: +ves and -ves

Health Structure

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GP history

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Primary care strategy 2001-Govt policy • Change in funding at least to high needs areas-enrolment – work with

communities eg capitation + co payment –deal with chronic care issues

• More work done by nurses/nurse practitioner

• Population approach

• Quality improvement

• Co-ordinate care

• Reduce inequalities

• What worked –what did not – no models

Primary care strategy 2001#2

• Bold new direction-anticipating change in health care needs- more chronic/long term care

• Forgot to inform “general practice”

• Leading from the front but so far in the future that ‘over the horizon’- but inspired (BA experience)

• PHOs with community input –limited experience; GP controlled

• Too many PHOs some too big and some too small

Two world views

Public health Individual health

Health of pop/communities Health of individuals

Social justice ? Communists

Social determinants Family issues

Advocate for populations Advocate for individual

Community participation ? My patients are happy

Prevention Screening

Cost contained and fair

Policy

Two different universes

“no limit” for individual

Medicine/surgery

Two world views

Public health Individual health

Bring the best of both worlds

Jacksonian model –cross road

The Jacksonian Vision for Population Health

Who does Pop health

• PHOs well placed –high level– Housing insulation– Focussed programmes –funding– Quality improvement

• GPs can also do pop health – Don Berwick “talk is cheap and (medical) culture

always wins”- won’t be easy to change the world– Patients come with agenda; GPs can respond or include

their own agenda-ideally both – Smoking “should” always be an issue

Where are GPs

• Most stuck in 15” three month consultation– Funding for some (running a business) – Historical thinking- fear of capitation– Group practice really solo practitioners occupying

the same building for cost advantages (extreme)– Too focussed on the individual (NZ GP and pt

centred)– Service industry:local dairy versus accountant/lawyer– Trained to deal with the urgent not the important

Where can they be

• New models of care• Population approach to smoking• Group management for diabetes (Trento 2010)• Group smoking cessation • Repeat prescriptions by phone/email• Different times for patients

– Eg depression 30 minute funded visits (CMDHB) – 20 minute regular appointments (2 to 3

comorbidities

Population approach to smoking

• Tana Fishman (USA) “encouraged to record smoking –Greenstone clinic Manurewa

• Had little competitions as to best coder• Has to be easy to find

– GP cannot spend 2 minutes finding information 15 to 20 minute of consultation time

• Procare’s dashboard– Advantage of bigger PHO

Population approach to smoking #2• Did not plan to do a population approach• Fell over the idea• Having coded “everyone” then naturally started to

do ABC • How did we discover we were there

• 22 year old complaining

• Every clinician with every smoker at every visit- mantra

• Patients respect us• We are user friendly

Population approach to smoking #3• A quiet sense of satisfaction at all clinicians

asking every smoker at every visit• ASH at Warriors game • Lozenges at the front desk • Receptionist asks if person wants help with

smoking cessation• 3 per day often teenagers

GP range

• Those who think they should start the consultation discussing smoking to those who don’t think it is there responsibility

• Advocacy is not on the GP agenda– Not trained– Not a feature of their “tribe”; GP conversations

• “in love with drugs and devices” – Smoking cessation in heart patients 9% reduction in mortality in 2

years vs 3% in 5 years with statins • Chest 2007;131:446-52; lancet 1994;344:1383-9

Govt targets

• DHB league tables have worked– DHBs put on discharge summary– ?PHO league tables vs practice based

• ? PHO version – Sue Taffe NZ doctor 20 Oct 2010-Hawkes Bay– In house smoking cessation support – Simple recording eg off the dashboard– Cessation champion in each practice ???

Questions??

Future with PHOs

• Health targets- Pay for performance will get attention – Tony Ryall checks the tables

• Support from PHO and GP practice/owner• Clinical champions at practice level • Start slowly –likely resistance-will feel

overwhelmed– Eg coding→ intervention/referral – Funding

Future with PHOs #2

• Understand the local context– Eg Wellsford quality = having a GP on call

• Strategize; experience from others

• User friendly GPs

• Develop relationship with PHO one by one– Not very co-operative ? competitors

Future with PHOs-Barriers

• Financial and staff resources• Good clinical information systems• Too busy staff• No payment for quality work • Doctor/nurse resistance

• Rundall et al BMJ 2002;325:958-61

Future with PHOs-enhancers

• Organisation culture supports improvement• Computerised health record• Supportive medical and managerial leadership• Organisations strategic plan

• Rundall et al BMJ 2002;325:958-61

Future

• Smoke free Aotearoa 2020• Role of Schools

– ASH year 10 survey smoking going down

• High schools have nurses primary schools share• “Captive” students –can follow up • Sore throat clinic getting this started

– Many steps to get established (Rh fever prevention)

• Smart cafeterias; exercise; smoking – Risk taking training

Why should GPs do smoking cessation• 66% of smokers die from smoking

– Smoking risk me with 40 kg– We know other risk factors eg BP, cholesterol

• Stop two smokers save one life• Most people give up on their own

– So why bother

• Part of the “population approach”• Personal relationship

– Some patients “waiting” for GP to discuss smoking

• Smoking the elephant in the room – Sue Taffe NZ Doctor 20 Oct 2010-Hawkes Bay

War stories #1

• Gentle ways of encouraging– You are 30 good age to give up (no further harm)– You are 50 good age to give up (avoid emphysema)– You are 60 (tiger country) stroke coming

• If have children do you want them to be smokers - never

• Plead: as a GP I see the damage and then people give up. How about giving up with good health

• What would it take to give up –what like to be smokefree

War stories #2

• Excuses• I do it to relax- how can we find a safer way to

relax• Smoking is “good” for you. It makes you take

time out and breath deeply. How can we get the time out without the dangerous smoke

• If quit before what did they do that time

War stories #3

• The big story• 55 year old Maori woman smoking a packet per day • Looked on dashboard and saw “smoker”• Question → rebuff

• I do it to relax- how can we find a safer way to relax• Smoking is “good” for you. It makes you take time out and breath

deeply. How can we get the time out without the dangerous smoke• If quit before what did they do that time

Questions

• The role of schools?

Questions

• PHOs and the +ves and -ves

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