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The Medical Team of the Future
IHCA October 2010
The Medical Team of the Future
PLAN:
Address health issues in the developed world looking into the future
Look at what's happening in Ireland
Identify some of the drivers of the Medical Team of the Future
IHCA October 2010
200 interviews with leaders in 25 countries
3,700 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 diseases
2. Their associated behavioural, socioeconomic, and genetic factors
3. Digitisation
Health will be customized around five vectors
Incentive-based payment
Doctors to follow best practice
Funding.
Redistributed from sickness to wellness
Patient communication improvement
To engage individuals in their own health
Electronic medical records (EMRs)
By 2020
Workforce
Systems more efficient. More primary care
physicians
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
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.
Have we started to anticipate trends identified by PWC?
A new direction of travel
The service should be designed for Users - not Providers
How far are we down the road to transformation?
1.
2.
3.
4.
5.
6.
7.
250 Primary Care Teams established
Hospitals have been “re-shaped”
Performance measures are driving change
Developed Clinical Leadership
Changed organizational structure to deliver integrated care
Improved value for money
Information technology to support integration
-little achieved so far
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?
The Medical Team of the Future
DRIVERS
New Health Service and
Hospital configuration
Hospital configuration
New models of service
Medical staffing
delivery
UNDERSTANDING
THE NATURE OF
TEAMWORK
NewService
modelsdelivery
of medical
staffing
Networking
and
New models
of networking
communication
and
communication
The Medical Team of the Future
DRIVERS
New Health Service and
Hospital configuration
Hospital configuration
New models of service
Medical staffing
delivery
UNDERSTANDING
UNDERSTANDING
THE
THE NATURE
NATURE OF
OF
TEAMWORK
TEAMWORK
New models of medical
Service delivery
staffing
Networking
and
New models
of networking
communication
and
communication
UNDERSTANDING TEAMWORK
Widely accepted by business schools, corporations, aviation, nuclear industry,
military services and emergency responders
The 20th Century Physician
● Accumulated knowledge
● Supported in autonomous pursuits
● Cooperated
● Individual achievement
● Solo experts (physician-centered)
The 21st Century Physician
● Must continually acquire and use knowledge
● Must be collaborative
● Must share accountability
● Interdisciplinary team achievement
● involved in coordination of care (patient-centered)
“The Team is the Medicine of the Future”
The Medical Team of the Future
DRIVERS
New Health Service and
Hospital configuration
Hospital configuration
New models of service
delivery
UNDERSTANDING
THE NATURE OF
TEAMWORK
New models of medical
staffing
New models of networking
and communication
HISTORY OF ATTEMPTS AT HOSPITAL RECONFIGURATION
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
HOSPITAL RECONFIGURATION
Contemporary: “Re-shaping” of Hospitals
Acute Medical Programme
HSE/DQCC/RCPI
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
DEFINE
MEDICAL TEAMS
4 HOSPITAL
MODELS
NAVIGATIONAL
HUBS
PRIMARY
CARE TEAMS
INTEGRATED SERVICE AREA
The Medical Team of the Future
DRIVERS
New Health Service and
Hospital configuration
New models of service
Medical staffing
delivery
UNDERSTANDING
THE NATURE OF
TEAMWORK
New models of medical
staffing
New models of networking
and communication
Hospital Teams
HANLY
HANLY
•Anticipated numbers
• Meet requirements of EWTD
• Achieve consultant provided service
2003
2010
1,731
2,375
NCHDs
3,943
4,800*
Nurses
-
Consultants
* Training = 3,600; Non-training = 1,200
Contracts of indefinite duration = 7-800; Taken up = 75
37,384°
2013
3,600
2,200
-
° Public Sector
20, 284 Acute Sector
2,300 specialist & advanced practitioner role
CAREER PATH
MEDICINE
Student
Student
NURSING
4yrs
4-6yrs
RGN
Doctor
2-5yrs
5-8yrs
6-9yrs
CNM 1
2-3yrs
CNS
Specialist
Consultant
CNM 2
CNM 3
ANP
Assistant Director
?
Prescribing, IV cannulation, Examination newborns and sexual assaults
Minor skin procedures and Endoscopy etc
CAREER PATH
MEDICINE
Student
4-6yrs
Doctor
6-9yrs
Specialist
Consultant
?
CAREER PATH
Student
NURSING
4yrs
RGN
2-5yrs
5-8yrs
CNM 1
2-3yrs
CNS
CNM 2
CNM 3
ANP
Assistant Director
Prescribing, IV cannulation, Examination newborns and sexual assaults
Minor skin procedures and Endoscopy etc

Anaesthesia

Genito-Urinary Medicine

Palliative Medicine

Cardiology

Geriatric Medicine

Plastic Surgery

Cardiothoracic Surgery

Haematology

Psychiatry

Chemical Pathology

Histopathology

Public Health Medicine

Clinical Microbiology

Immunology

Radiology

Clinical Pharmacology and
Therapeutics

Infectious Diseases

Rehabilitation Medicine

Medical Oncology

Renal Medicine

Neurology

Respiratory Medicine

Neurosurgery

Rheumatology

Obstetrics & Gynaecology

Sports & Exercise Medicine

Occupational Medicine

Trauma & Orthopaedic Surgery

Ophthalmology

Urology

Oral & Maxillofacial Surgery

Otolaryngology Head & Neck
Surgery

Paediatric Surgery

Dentistry

Dermatology

Emergency Medicine

Endocrinology/ Diabetes Mellitus

Gastroenterology

General (Internal) Medicine

General Paediatrics

General Practice

General Surgery
ANOTHER GRADE ?
“To continue to staff our hospital system with nothing but consultants and
junior doctors in training posts is absolutely impractical,”
Prof Brendan Drumm
…… 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.
A NEW CAREER PATH
Student
MEDICINE
4-6yrs
Doctor
6-9yrs
Specialist/
Consultant
Complex care
Management
Education
Research
Senior Consultant
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
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
The Medical Team of the Future
DRIVERS
New Health Service and
Hospital configuration
New models of service
delivery
UNDERSTANDING
THE NATURE OF
TEAMWORK
New models of medical
Service delivery
staffing
New models of networking
and communication
New Clinical Programmes
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
Access
Quality
Cost
Average length of Stay
Ireland Vs UK: Even though Ireland has a younger population, patients spend
up to almost 2 days longer in hospital for the same procedures
2.5
2.0
1.9
Average length of
stay is among the
longest in OECD.
WEIGHTED DIFFERENCE IN ALOS BETWEEN
UK AND IRELAND (AGE ADJUSTED)
1.8
1.5
1.4
1.4
1.2
1.0
0.7
0.7
0.6
0.5
-
Gynaecology
Critical Care
Source: HIPE 2005 & UK Department of Health
Obstetrics
Paediatrics
Surgical
Medical
Other
COSTS; Bed €995/day (€ 160=variable) Theatre €2,558,421/yr (50%=variable)
Acute Medicine Programme
• Acute Medicine Physician
• Case Managers
Elective Surgery Programme
To 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?
The Medical Team of the Future
DRIVERS
New Health Service and
Hospital configuration
Hospital configuration
New models of service
Medical staffing
delivery
UNDERSTANDING
UNDERSTANDING
THE
THE NATURE
NATURE OF
OF
TEAMWORK
TEAMWORK
New models of medical
Service delivery
staffing
Networking
and
New
models of networking
and communication
communication
IT SYSTEMS; AUDIT; ACCURATE DATA
DEFINE
MEDICAL TEAMS
CASE
MANAGERS
4 HOSPITAL
MODELS
NAVIGATIONAL
HUBS
PRIMARY
CARE TEAMS
UNIQUE PATIENT IDENTIFIER, ELECTRONIC MEDICAL RECORDS
DO WE HAVE A CHOICE?