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?