national clinical strategy transformational survival? grampian ... · political desire for...
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National Clinical Strategy Transformational Survival? Grampian Strategic Planning Event 9th December 2015
Moving on from the 2020 vision
“ Just how fresh are these insights??”
Requirements:
Political desire for transformational change
Chief Executives need for sustainability
Must be evidence based
Must enhance quality & be clinically credible
“I’ll be happy to give you completely innovative thinking. What are the guidelines?”
The Challenges:
Demographic Change.
Rise of long term conditions.
Health Inequalities.
Medical Staffing challenges.
Financial challenges.
Social work vs Healthcare Balance.
Over-medicalisation.
£20,000,000
£22,000,000
£24,000,000
£26,000,000
£28,000,000
£30,000,000
£32,000,000
2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 (Proj)
Primary Care Expenditure (GIC)
£-
£2,000,000
£4,000,000
£6,000,000
£8,000,000
£10,000,000
£12,000,000
£14,000,000
£16,000,000
£18,000,000
2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 (Proj)
Secondary Care Prescribing
Dumfries & Galloway Prescribing Patterns:
Overwhelming need for Realistic Medicine
Solutions:
Public Health?
Essential must-dos – such as alcohol pricing, sugar tax, exercise, mental health & wellbeing (not SG policy yet)
Social change has significant impact: - income,poverty,education
But unlikely to have significant impact in next 5-10 years?
Why prioritise primary care?
“The Cost Conundrum” & failure demand
Incremental and personalised approach
Managing risk professionally
Generalist approach & co-ordination of care.
Primary & Community Care: Priority
Multidisciplinary team working
Collaboration between practices
Access initiatives
Self – Management (?) + “Community Assets”
New GMS contract: must provide appealing career
GP focus on complex cases
Move away from QoF (from April 2016)
Address polypharmacy, anticipatory care
Social work integration
Understand patient priorities
Role must include keeping patients out of hospital
OOHs review now complete
Cost and quality of experience
Self care
Supported self care
Care at home
Hospital at home
Residential care
Acute Care Bet
ter
exp
eri
ence
In
creasing
costs
Increasin
g risk o
f harm
Secondary Care: Process & Structure
Secondary Care: Process & Structure
Need to accelerate work on processes:
Enhanced recovery after surgery
Out-patients
Unscheduled care
Nurse led discharge
Discharge Delay:
Accounts for 151,000 bed days per quarter
Equivalent to 1,600 beds across Scotland
Must change – high cost/poor experience/harm
Secondary Care Structure:
Workforce and cost constraints suggest fewer in-patient sites.
Volume-Outcomes issues relevant in more complex presentations
eg: Radical Prostatectomy
Complex Cancers
Orthopaedics
Ophthalmology
Vascular Surgery
Stroke Services
Secondary Care Structure:
Planning on local/regional/national basis.
Reduced number of in-patient units
Diagnostics/out-patients/day case available in most hospitals.
Must ignore health board boundaries and focus on benefits.
Potentially better utilisation of doctors.
Potential for cash savings must not be ignored.
A new clinical paradigm?
Are we under-resourced? Or “over-supplying”?
Why a new paradigm?
30 years of evidence based medicine
-but realisation of limits/commercial influences?
-treatment of risk?
Variation not explained by need
Wasteful interventions of doubtful value
Need for professionalism/patient engagement
Problems with Guidelines:
Study of articles in NEJN over 1 year (2009)
124 studies of medical practices
35 reviewed practices already in place
16 advised “reversal” of standard guidance
Prasad V: Archives of Internal Medicine: Vol 171 (18); pp1675-1676
The Academy of Royal Colleges believes:
There is evidence of a considerable volume of
inappropriate clinical interventions
The reasons for this are complex and various but form
part of a culture of over-medicalisation
The result is sub-optimal care for patients which, at
best, adds little or no value and, at worst, may cause
harm
This is, therefore an issue for clinicians about the
quality and appropriateness of care
Academy of Medical Royal Colleges:
A new Clinical Paradigm??
BMJ Overdiagnosis series
JAMA “Less is More”
“Being Mortal” and King’s Fund paper on patient preferences
Academy of Royal Colleges (“20% health interventions of only marginal benefit”)
“Prudent Healthcare” in Wales
Evidence of waste and excess variation Polypharmacy
Understanding Risk Spending in last year of life of limited value in many cases –
and may harm.
Doctors as potential patients
New variant of avian flu sweeping country
Without IgG: 10% death rate
30% hospitalisation
With IgG: 5% death from flu
15% hospitalised
but 1% die from IgG
4% paraplegic
Doctors as potential patients
700 family physicians asked about treatment:
37% chose to have IgG themselves
48% chose this for patients
Doctors are not the ones who get the side effects when treatments are
provided and are influenced strongly by guidelines/peer pressure
Ubel et Al: “Physicians recommend different treatments for themselves”: Archives of Internal Medicine: vol 171 no 7 630-4 2011
{Doctors generally chose less treatment for themselves than they suggest for patients.} {Patients who are fully informed choose less treatment and have less regret}
Expenditure in last year of life?
Summary:
Change is inevitable and urgent
Summary:
Plan primary care round communities
Plan acute care around networks
Promote realistic medicine, and self-resilience
Enhanced technology
Multi-disciplinary approach
Questions / Comments?