The Medical Team of the Future
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The Medical Team of the Future
IHCA October 2010
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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
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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
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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
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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
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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.
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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
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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?
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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
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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
UNDERSTANDING THE NATURE OF
TEAMWORK
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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
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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
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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
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Contemporary: “Re-shaping” of Hospitals
Acute Medical ProgrammeHSE/DQCC/RCPI
HOSPITAL RECONFIGURATION
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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
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PRIMARY CARE TEAMS
NAVIGATIONAL HUBS
4 HOSPITAL MODELS
DEFINEMEDICAL TEAMS
INTEGRATED SERVICE AREA
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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
Medical staffing
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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
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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
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Student
Doctor
SpecialistConsultant
4-6yrs
6-9yrs
CAREER PATH
MEDICINE
?
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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
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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
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…… 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
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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
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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
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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
Service delivery
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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
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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)
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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?
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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
UNDERSTANDING THE NATURE OF
TEAMWORK
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PRIMARY CARE TEAMS
NAVIGATIONAL HUBS
4 HOSPITAL MODELS
DEFINEMEDICAL TEAMS
CASE MANAGERS
IT SYSTEMS; AUDIT; ACCURATE DATA
UNIQUE PATIENT IDENTIFIER, ELECTRONIC MEDICAL RECORDS
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DO WE HAVE A CHOICE?