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
Health Structure
• Government
• Ministry-advice only
• District Health Boards
(20)
• (Fund hospitals & GP)
• PHOs-Primary Health (78→55)
• GP s (3000)
3
GP history
• Corner dairy (pre 1990s)
• Transition phase
• 2010 population approach
• Cross road
4
Primary care strategy 2001-Govt
policy
• Change in funding at least to high needs areasenrolment – 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
Two world views
Public health
Individual health
Health of pop/communities
Health of individuals
Social justice
? Communists
Social determinants
Family issues
Advocate for populations
Advocate for individual
Community participation
? My patients are happy
Prevention
Screening
Cost contained and fair
“no limit” for individual
Policy
Medicine/surgery
Two different universes
Two world views
Public health
Bring the best of both worlds
Jacksonian model –cross road
Individual health
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 ???
Questions??
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
Questions
• The role of schools?
Questions
• PHOs and the +ves and -ves
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