The Pisa Syndrome: reflections on Patient Centred Innovation and Organizational Change

1. The Pisa Syndrome:reflections on Patient Centred Innovation and Organizational Change Prof. Jan M. De Maeseneer, MD PhD Head of Department of Family Medicine and Primary Health Care – GhentUniversity Director Primafamed-CentreGhentUniversity Pisa, 31.08.10

2. The Pisa syndrome • Clinical approach • Major diagnostic components • From chronic disease management to participatory patient management • The way forward

4. Pleurothotonus • Abnormallyposturing • Flexion of the body and head to one side • Slight axial rotation of the trunk • Cause: long-term use of neurolepticmedication • Recent report: cholinesteraseinhibitors • Source: The Lancet, 2000; 355:2222 Clinical presentation

6. The Pisa syndrome • Clinical approach • Major diagnostic components • From chronic disease management to participatory patient management • The way forward

7. Major diagnosticcomponents • Guidelines are not based on research in PC, none is based on research with complex multimorbidity • You talk to patients, you do not enrol them. • (G. Tognoni)

8. Major diagnosticcomponents Strengthening primary care: Important differences in context and national strategies Weak incentives and voluntary basis: Is it enough? How to convince governments, doctors, insurance organisations, patients of the urgency? How to balance paternalism and patient choice? EU-countries provide a laboratory for comparative research (P. Groenewegen)

9. Major diagnosticcomponents As reported by FD and nurses in NDPHS Workshop “Tomorrows role of Family doctors and Nurses” (Baltic Conference of Family Medicine, Piarnu, Estonia Sept 2009) • Unequal distribution of PHC practices – not attractive rural areas • Increasing workload • Extended PHC team needed • More emphasis on patient centered, holistic care • Introduction of EB performance indicators • Apropriate incentive payment schemes(A. Jurgutis)

10. Major diagnosticcomponents • System change depends on • External pressure • Internal “strategic” interventions • Incremental but strategic “little steps” • System change takes time • (H. De Ridder)

11. Strategy for Change in Health Systems • Achieving primary care • Avoiding an excess supply of specialists • Achieving equity in health • Addressing co- and multimorbidity • Responding to patients’ problems • Coordinating care • Avoiding adverse effects • Adapting payment mechanisms • Developing information systems that serve care functions as well as clinical information • Primary care-public health link: role of primary care in disease prevention (B. Starfield)

12. The Pisa syndrome • Clinical approach • Major diagnostic components • From chronic disease management to participatory patient management • The way forward

14. From problem-oriented togoal-oriented medical care:A paradigm-shift Source: Mold J et al, Fam Med 1991;23:46-51

15. “Problem-oriented versus goal-oriented care”

16. “Problem-oriented versus goal-oriented care”

17. Whatreallymatters for patients is • Functionalstatus • Social participation

18. PHC and Contextual Evidence From“chronic disease management” “participatorypatientmanagement”

19. ‘ChronicDisease Management’ mightlead to verticaldiseaseoriented programs, leading to inequitybydisease [ seewww.15by2015.org ]

20. Clinical Secondary prevention of coronary heart disease Cardiovascular disease: primary prevention Heart failure Stroke & TIA Hypertension Diabetes mellitus COPD Epilepsy Hypothyroid Cancer Palliative care Mental health Asthma Dementia Depression Chronic kidney disease Atrial fibrillation Obesity Learning disabilities Smoking Organisational Records and information Information for patients Education and training Practice management Medicines management Patient experience Length of consultations Patient survey (access) Additional services Cervical screening Child health surveillance Maternity services Contraception Domains for quality indicators in QOF 2009

21. Patient experience • Little research on patient related/reported impact • Continuity and relationship affected • Fragmentation of care • Little explanation provided to patients “A slim, active 69-year-old patient attending for influenza vaccine was faced with questions about diet, smoking, exercise and alcohol consumption. There was no explanation for why these questions were asked; they seemed irrelevant to having a ‘flu vaccine. Blood pressure and weight had to be recorded and a cholesterol test organised. A short appointment lasted almost 15 minutes without the patient having the opportunity to ask a question about any aspect of ‘flu vaccine.” Wilkie. Does the patient always benefit? In…

22. The Pisa syndrome • Clinical approach • Major diagnostic components • From chronic disease management to participatory patient management • The way forward

23. The wayforward • translational research • education • policy development • threats and opportunities • leadership

24. The wayforward • translational research • education • policy development • threats and opportunities • leadership

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33. Quality of care Medical Contextual Efficacy Effectiveness Efficiency & equity Policy EVIDENCE

36. The wayforward • translational research • education • policy development • threats and opportunities • leadership

37. THE FIVE STAR DOCTOR WHO-five star doctor • assess and improve the quality of care • make optimal use of new technologies • promote healthy lifestyles • reconcile individual and community health requirements • work efficiently in teams

38. Needforinterprofessionallearning

39. www.the-networktufh.org

40. Towards socially accountable faculties: ACTION IS NEEDED! ACTION IS NEEDED!

41. We invite you for the next EFPC conference in Graz on September 16, 2011 in Austria Followed by the AnnualConference of the Network TowardsUnity For Health (TUFH) : Integrating Public and Personalhealth care in a world on the move. 17-22 Sept 2011

42. The wayforward • translational research • education • policy development • threats and opportunities • leadership

43. The Effectiveness of QI Strategies: findings from a Recent Review of Diabetes Care Shojania, K. G. et al. JAMA 2006;296:427-440.

44. Policies improving cost efficiency “The governmentshouldstronglyencouragepatients to consult theirgeneralpractitionerfirst as a generalrule (exceptforemergencies) bynotreimbursingmedicalexpensesforpatientsnotreferredbytheir GP (gatekeeper).” OECD economic surveys 2005 - Belgium, pag 68

46. Keyrecommendations of the Marmot Review • There is a social gradient in health – the lower a person’s social position, the worse his or her health. Action should focus on reducing the gradient in health. • Health inequalities result from social inequalities. Action on health inequalities requires action across all the social determinants of health. • Focusing solely on the most disadvantaged will not reduce health inequalities sufficiently. To reduce the steepness of the social gradient in health, actions must be universal, but with a scale and intensity that is proportionate to the level of disadvantage. We call this proportionate universalism.

47. Healthy life expectancy in Belgium (Bossuyt, et al. Public Health 2004) Socio-economic inequalities in health

48. Healthy life expectancy in Belgium (Bossuyt, et al. Public Health 2004) Socio-economic inequalities in health

49. Keyrecommendations of the Marmot Review • Reducing health inequalities will require action on six policy objectives: • Give every child the best start in life • Enable all children young people and adults to maximise their capabilities and have control over their lives • Create fair employment and good work for all • Ensure healthy standard of living for all • Create and develop healthy and sustainable places and communities • Strengthen the role and impact of ill health prevention

50. Integration of welfare and health