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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?