The Medical Team of the Future

The Medical Team of the Future

IHCA October 2010

The Medical Team of the Future

IHCA October 2010

PLAN:

Address health issues in the developed world looking into the futureLook at what's happening in IrelandIdentify some of the drivers of the Medical Team of the Future

200 interviews with leaders in 25 countries3,700 consumers in 7 countries

• Care in the future will be customized to the individual

• Models of care are struggling to keep up with volumes

• Change is being driven by three key issues:1. Chronic diseases2. Their associated behavioural, socio-

economic, and genetic factors3. Digitisation

Health will be customized around five vectors

Incentive-based paymentDoctors to follow best practice

Funding. Redistributed from sickness to wellness

Patient communication improvementTo engage individuals in their own health

Electronic medical records (EMRs) By 2020

WorkforceSystems more efficient. More primary care physicians

Individuals’ relationships with health delivery models are changing. Consumers now want:

Better coordination of care Coordinated care teams Fluent navigators

Chronically ill patients need help to navigate the health system

Their experiences to be benchmarked

To access innovation sooner

Availability of medical tourism to increase

Care-anywhere networks Redefined by the ubiquity of mobile devices

Ireland – the Future

In next 30 years:Population ↑ 16-67%Age>65 from 15.9% to 40%

Last Census - 400,000 chronic health condition or disability (60% > 60yrs)

Age + increasing risk factor prevalence – obesity, physical inactivity, alcohol• ↑Diabetes 4.7% to 5.7-7.4%• ↑Cancer by 2020 by 15% in women; 8.5% in men

............curtailed resource.

A new direction of travelThe service should be designed for Users - not Providers

Have we started to anticipate trends identified by PWC?

How far are we down the road to transformation?

1. 250 Primary Care Teams established2. Hospitals have been “re-shaped”3. Performance measures are driving change 4. Developed Clinical Leadership 5. Changed organizational structure to deliver integrated care 6. Improved value for money 7. Information technology to support integration -little achieved so far

The stated objectives of Irish health policy

• The patient must be central to any planning process

• The right services must be delivered with the right skills in the right facilities at the right places

• The service must be fair, equitable and focused on greatest needs

• The service must be efficient, sustainable, joined up and fit for purpose

How will the Medical Team of the Future enable this to happen?

Will the Medical Team be the driver of change or will it evolve as the result of change imposed upon us?

The Medical Team of the FutureDRIVERS

New Health Service and Hospital configuration New models of service

delivery

New models of medical staffing

New models of networking and communication

UNDERSTANDING THE NATURE OF

TEAMWORK

Hospital configuration Medical staffing

Service delivery Networking and communication



delivery




TEAMWORK




TEAMWORK

UNDERSTANDING TEAMWORK

The 20th Century Physician The 21st Century Physician

● Accumulated knowledge ● Must continually acquire and use knowledge● Supported in autonomous pursuits ● Must be collaborative● Cooperated ● Must share accountability● Individual achievement ● Interdisciplinary team achievement● Solo experts (physician-centered) ● involved in coordination of care (patient-centered)

“The Team is the Medicine of the Future”

Widely accepted by business schools, corporations, aviation, nuclear industry, military services and emergency responders



delivery




TEAMWORK

Hospital configuration

1968 Fitzgerald Report 1993 Tierney Report 2001 Quality and Fairness

2003 Hanly Report

2007 National Cancer Control Programme• not a model on which to shape a Medical Team

HISTORY OF ATTEMPTS AT HOSPITAL RECONFIGURATION

Contemporary: “Re-shaping” of Hospitals

Acute Medical ProgrammeHSE/DQCC/RCPI

HOSPITAL RECONFIGURATION

Model 1 •Community/District Hospital, Patients under the care of GP/Medical Officer

Model 2•In-patient and OPD care for differentiated,

low-risk medical patients•Day Surgery•MIU

Model 3•Undifferentiated acute medical in-patients•Elective Day & In-patient Surgery of larger

specialties; some cancers•24-hour ED

Model 4•Undifferentiated acute medical patients•Elective In-patient Surgery - Major, Cancer,

National and Regional specialties•24-hour ED

PRIMARY CARE TEAMS

NAVIGATIONAL HUBS

4 HOSPITAL MODELS

DEFINEMEDICAL TEAMS

INTEGRATED SERVICE AREA



delivery




TEAMWORK

Medical staffing

Hospital Teams

2003

2010

2013

Consultants 1,731 2,375 3,600

NCHDs 3,943 4,800* 2,200

Nurses - 37,384° -

* Training = 3,600; Non-training = 1,200 Contracts of indefinite duration = 7-800; Taken up = 75

° Public Sector 20, 284 Acute Sector 2,300 specialist & advanced practitioner role

HANLY • Meet requirements of EWTD• Achieve consultant provided service

HANLY• Anticipated numbers

Student

Doctor

SpecialistConsultant

4-6yrs

6-9yrs

Student

RGN

CNM 1

4yrs

2-5yrs

CNM 22-3yrs

CNM 3

CNS

5-8yrs

Assistant DirectorANP

CAREER PATH

MEDICINE NURSING

?Prescribing, IV cannulation, Examination newborns and sexual assaultsMinor skin procedures and Endoscopy etc

Student

Doctor

SpecialistConsultant

4-6yrs

6-9yrs

CAREER PATH

MEDICINE

?

Student

RGN

CNM 1

4yrs

2-5yrs

CNM 22-3yrs

CNM 3

CNS

5-8yrs

Assistant DirectorANP

CAREER PATH

NURSING

Prescribing, IV cannulation, Examination newborns and sexual assaultsMinor skin procedures and Endoscopy etc

Anaesthesia Cardiology Cardiothoracic Surgery Chemical Pathology Clinical Microbiology Clinical Pharmacology and

Therapeutics Dentistry Dermatology Emergency Medicine Endocrinology/ Diabetes

Mellitus Gastroenterology General (Internal) Medicine General Paediatrics General Practice General Surgery

Genito-Urinary Medicine Geriatric Medicine Haematology Histopathology Immunology Infectious Diseases Medical Oncology Neurology Neurosurgery Obstetrics & Gynaecology Occupational Medicine Ophthalmology Oral & Maxillofacial Surgery Otolaryngology Head & Neck

Surgery Paediatric Surgery

Palliative Medicine Plastic Surgery Psychiatry Public Health Medicine Radiology Rehabilitation Medicine Renal Medicine Respiratory Medicine Rheumatology Sports & Exercise Medicine Trauma & Orthopaedic Surgery Urology

…… he had in mind the UK staff grade doctor, or the specialty doctor grade that replaced the staff and associate specialist grades (SAS) in 2008, but he was not sure if the UK model had worked particularly well.

“To continue to staff our hospital system with nothing but consultants and junior doctors in training posts is absolutely impractical,”

ANOTHER GRADE ?

Prof Brendan Drumm

Student

Doctor

Specialist/Consultant

4-6yrs

6-9yrs

A NEW CAREER PATH

MEDICINE

Senior Consultant

Complex careManagementEducationResearch

Advantages• This provides an incentivised career structure• Earlier appointments as consultants• Fostered within the team concept• New and lower starting salary• Significant bonus for achieving ‘Seniority’• Avoids the use of demeaning titles• Sustains the concept and virtues of a consultant provided service

NCHDs and EWTD

Physician Assistant

• Developed in ‘60s in USA; Vietnam (60,000)• Australia, Canada, Netherlands, Sth Africa, UK• Graduate entry programme• 3 years; Classroom and lab; in medical & behavioural sciences• Programmes accredited internationally• Model designed to complement Medical training• After graduation work and learn within a clinical team• Extensive range of clinical activities under supervision• Permanence



delivery




TEAMWORK

Service delivery

AccessQualityCost

Twenty created in response to:

• Hospitals overloaded with acute medicine & chronic diseases• Poor capacity for elective surgery• Inefficient use of resources• Inconsistent practice• Poor data

Solutions

• Programmes for acute medicine & chronic diseases• Program for elective surgery

New Clinical Programmes

Ireland Vs UK: Even though Ireland has a younger population, patients spend up to almost 2 days longer in hospital for the same procedures

Source: HIPE 2005 & UK Department of Health

WEI

GHTE

D DI

FFER

ENCE

IN A

LOS

BETW

EEN

U

K AN

D IR

ELAN

D (A

GE A

DJU

STED

)

1.8

1.9

0.7

1.4

0.6

1.4

1.2

-

0.5

1.0

1.5

2.0

2.5

Critical CareGynaecology MedicalObstetrics OtherPaediatrics Surgical

0.7

Average length of stay is among the longest in OECD.

Average length of Stay

COSTS; Bed €995/day (€ 160=variable) Theatre €2,558,421/yr (50%=variable)

Acute Medicine Programme• Acute Medicine Physician• Case Managers

Elective Surgery ProgrammeTo address the blocks

• Poor access to out-patient investigations• Inconsistent or poor

Day surgery services & practice Pre-admission assessment clinics Day of surgery admissions Access to ring-fenced beds

Acute Surgery Programme• Acute General Surgeon?



delivery




TEAMWORK




TEAMWORK

PRIMARY CARE TEAMS

NAVIGATIONAL HUBS

4 HOSPITAL MODELS

DEFINEMEDICAL TEAMS

CASE MANAGERS

IT SYSTEMS; AUDIT; ACCURATE DATA

UNIQUE PATIENT IDENTIFIER, ELECTRONIC MEDICAL RECORDS

DO WE HAVE A CHOICE?

Documents

The Medical Team of the Future