Engaging the primary care sector

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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
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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

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Health Structure
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GP history
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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

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Primary care strategy 20012

• 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

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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 Policy Two different universes no limit for individual Medicine/surgery
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Two world views
Public health Individual health
Bring the best of both worlds Jacksonian model cross road






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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

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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- wont 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

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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 industrylocal dairy versus
  accountant/lawyer
• Trained to deal with the urgent not the important

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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

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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
• Procares dashboard
• Advantage of bigger PHO

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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

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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

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GP range

• Those who think they should start the
  consultation discussing smoking to those who
  dont 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 2007131446-52 lancet 19943441383-9

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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 ???

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Questions??

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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

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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

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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 2002325958-61

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Future with PHOs-enhancers

• Organisation culture supports improvement
• Computerised health record
• Supportive medical and managerial leadership
• Organisations strategic plan
• Rundall et al BMJ 2002325958-61

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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

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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

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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

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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

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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

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Questions

• The role of schools?

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Questions

• PHOs and the ves and -ves

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