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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
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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
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
The Jacksonian Vision for Population Health Public Health Population Health Individual (elderly, children, men, women,9rdd Maori and Pacific people, women, children elderly Other subgroups: Rest homes. After hours patients Schools
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 ???
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
