Allmänläkaren 2020 onödig eller oumbärlig? Steinar Hunskår

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1 SFAMs høstmøte 2010: UTSIKT Åre, 14 oktober 2010 Allmänläkaren 2020 onödig eller oumbärlig? Steinar Hunskår Professor, Universitetet i Bergen & allmennlege (fastlege for 400 personer)

2 Innhold Den allmänmedicinska ideologin står under press från många håll. Kanske är den en postmodern anomali? Ett försök att belysa hur det klassiska innehållet i allmänmedicin kan förenas med moderna strömningar. Aktuella nyckelord: WHO, Obamas hälsoreform, kvalitetsindikatortyranniet, EU:s direktiv om gurkans böjning! Eller: An expert is a person more than 50 miles from home, with no responsibility for his advice, and who is showing slides Eller: Ein lett forvirrande og usystematisk allmennmedisinsk turné til Norge, Sverige, USA og Sudan!

3 An academic or practical field can be defined as a topic that can be incorporated in a textbook Unknown

4 General practice is a field of its own! Six core competencies Primary care management Person-centred care Specific problem-solving skills A comprehensive approach A community orientation A holistic approach

5 General practice; not only a good idea, But is proven to give Better total health Lower cost for same benefit Better distribution of community health Better priorities

6 General practice in a postmodern time The conclusion of a series of papers published in the Feb 4, 2003, issue of the Annals of Internal Medicine; "Primary care is in crisis the field has failed to hold its own among medical specialties". "Would it make a difference if the field were to fail?", ask the authors of another paper.

7 Challenges What does the market (the patients and the governments and the payers) want? Are core values like continuity and comprehensiveness outdated? How do we explain that we are specialists in something general? Is it good enough to be good in general? Is there increasing disagreement between GPs and hospital specialists?

8 Auka servicegrad

9 S Who should have the Total Body Screening CT-scan?

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13 Gode råd frå Geneve Mange politikarar kjenner: LEON-prinsippet Færre kjenner: Den personlege legen Kontinuitet Koordinatorrolla og verdien av tilvisingssystemet Fra PORTVAKT til MEDISINSK KNUTEPUNKT og MEDICAL HOME

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15 Sterke og svake sider ved den norske fastlegeordninga Vi startar i Norge!

16 Fastlegeordninga fra ein suksess! For dei fleste pasientane... For dei fleste fastlegane... For dei fleste kommunane... For dei fleste politikarane...

17 Suksesskriterier for dei fleste pasientane... Fast stad å henvende seg, alle papir samla Ein som kjenner meg og sjukdommane mine Ein som ordnar opp for meg i mange slags saker Tillit til legen sin som person, den personlege legen Tilgjenge til time og på telefon

18 Suksesskriterier for dei fleste fastlegane... Fast pasientpopulasjon og stabil økonomi Høgt medisinsk og teknologisk nivå Definerte oppgåver, godt samarbeid lokalt og mot sjukehus, henvisingsprinsippet Lite byråkrati, enkle betalingsordningar, får stort sett vere i fred med sitt Sjølvstendig næringsdrivande; stor fagleg og organisatorisk autonomi

19 Suksesskriterier for dei fleste kommunane og politikarane Betre legedekning Stabile og forutsigbare kostnader Lite klager på, og offentleg bråk frå, tenesta God pasienttilfredsheit Kan dermed sleppe å ha særleg fokus på dette området

20 Trusselbildet - eller: Stille før stormen? Auka ansvar og oppgåver Relativt tap av kapasitet og autoritet i høve til sjukehusa Dysfunksjonell atferd Manglande administrativ struktur og lite fagleg fellesansvar For stor klinisk variasjon og for få integrerte pasientforlaup For lite forpliktande samarbeid Legevakt ein naudetat i bakleksa

21 Unbalanced growth in costs between primary and secondary care 21

22 Unbalanced growth in number of doctors j 20% 25% 31% -- GPs 22

23 Negativ tilpassing til tidsnaud og rammefaktorar! Korte konsultasjonar med mangelfullt klinisk innhald eller skjerming/manglande tilbod Dårleg oppfølgjing av kronisk sjukdom Viser pasientane til legevakta på ettermiddag Auka og unødvendig bruk av teknologi Eks blodprøver og MR Vill-screening (PSA, EKG, beintetthet) Mindre tid til heilheitleg tilnærming, og auka bruk av medikamentell behandling der samtale/rådgjeving kunne vore tenleg Depresjon og livskriser Hjarte-kar-risiko Antibiotikabruk, søvnvanskar

24 I. Fokus på sjukehus og spesialistteneste

25 Fragmentering. Helseteneste bygt på enkeltsaker, ikkje heilskap Svekka koordinatoransvar og rolla som alle pasientars rådgjevar og behandlar Enkeltsakslogikk framfor overordna tenking og systemforsvar Fastlegen skal ikkje gjere alt sjølv, men koordinere og prioritere. Nye yrkesgrupper Nye modellar The medical home The teamlet Chronic disease management

26 Så ein tur til USA

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32 Principles of the Patient-Centered Medical Home Am Fam Physician 2007; 76: Personal physician: each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous, and comprehensive care. Physician-directed medical practice: the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients. Whole-person orientation: the personal physician is responsible for providing for all of the patient's health care needs or taking responsibility for appropriately arranging care with other qualified professionals. This includes care for all stages of life, acute care, chronic care, preventive services, and end-of-life care.

33 Care is coordinated and/or integrated across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient's community (e.g., family, public and private community-based services). Care is facilitated by registries, information technology, health information exchange, and other means to ensure that patients get the care, when and where they need and want it. Quality and safety are hallmarks of the medical home. Practices advocate for their patients to support the attainment of optimal, patient-centered outcomes that are defined by a care planning process. Evidence-based medicine and clinical decision-support tools guide decision making. Physicians in the practice accept accountability for continuous quality improvement through voluntary engagement in performance measurement and improvement. Patients actively participate in decision making, and feedback is sought to ensure that patients' expectations are being met.

34 Information technology is used appropriately to supportoptimal patient care, performance measurement, patient education, and enhanced communication. Patients and families participate in quality-improvement activities at the practice level. Enhanced access to care is available through systems such as open scheduling, expanded hours, and new options for communication between patients, their personal physician, and practice staff. Payment appropriately recognizes the added value provided to patients who have a patient-centered medical home.

35 Allmennmedisin: Sverige og Norge i internasjonalt perspektiv

36 The Commonwealth Fund 2009 International Health Policy Survey of Primary Care Physicians in 11 Countries

37 $8 000 Health Care Expenditure per Capita by Source of Funding, 2007 Adjusted for Differences in Cost of Living $7 000 $6 000 $890 Out-of-Pocket Spending Private Spending Public Spending $5 000 $3 092 $720 $4 000 $3 000 $2 000 $1 000 $3 307 $38 $4 005 $1 350 $580 $627 $470 $589 $510 $449 $360 $2 618 $2 726 $2 844 $2 758 $528 $79 $2 716 $571 $343 $441 $204 $2 124 $2 446 $542 $88 $2 056 $0 US NOR SWIT CAN FR GER SWE AUS* UK ITA *2006 Source: OECD Health Data 2009 (June 2009)

38 Norwegian primary care is behind when it comes to... Quality assessment and review Sweden Europe USA All excl Norway Norway Clinical outcomes Patient satisfaction Clinical performance against targets yearly Clinical performance against other doctors

39 and Other personnel and their tasks Sweden Europe USA All excl Norway Norway Other personel Medication, Prescriptions, symptom tests, assessment prevention Patient education Life style councelling Practice netw orking

40 and do not use incentives for quality markers, same as in Sweden Incentives Sweden Europe USA All excl Norway Norway High patient satisfaction Achieve clinical targets Managing chronic diseases Enhanced preventive care Adding nonphysicians to team Non face to face consultations

41 Percent Doctors Use Electronic Patient Medical Records* NET NZ NOR UK AUS ITA SWE GER FR US CAN * Not including billing systems. Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

42 Computerized Capacity to Generate Patient Information Percent report the COMPUTERIZED capacity to generate: List of patients by diagnosis AUS CAN FR GER ITA NET NZ NOR SWE UK US List of patients by lab result List of patients who are due or overdue for tests/preventive care List of all medications taken by an individual patient* * Including those that may be prescribed by other doctors. Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

43 Percent 100 Doctor Receives Reminders for Guideline- Based Interventions or Screening Tests Yes, using a manual system Yes, using a computerized system AUS UK FR NZ ITA US CAN GER NET NOR SWE Percentages may not sum to totals because of rounding. Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

44 Doctors Perception of Patient Access Barriers Percent reporting patients OFTEN: AUS CA N FR GE R ITA NET NZ NOR SWE UK US Have difficulty paying for medications or other care Have difficulty getting specialized diagnostic tests Experience long waiting times to see a specialist Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

45 Percent* 100 Physician Satisfaction with Practicing Medicine Satisfied Very satisfied NZ NOR NET UK SWE ITA CAN FR US AUS GER * The other responses were somewhat dissatisfied or very dissatisfied. Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

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48 Allmennmedisinens utfordring: Kvalitetsindikatorer har effekt! Korleis unngå dei perverterte og uønska effektane? Korleis få det beste ut av det, til nytte for pasientar og myndigheter?

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51 The audit society: Regeleksplosjonen Revisjonssamfunnet Bygger på en filosofi om tvil, konflikt, mistillit og fare Metodar for revisjon er mange, vanlegvis arbeidskrevande og alltid kostbare

52 The ingredients of audit practice Independence from the matter being audited Evidence gathering and examination of the documentation Expression of a view based on the evidence A clearly defined object of the process; e.g. financial, sertification etc

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55 Regel- og revisjonssamfunnet som postmodernistisk prosjekt også i helsetenesta! Deregulering og fri marknad krev MEIR reglar, forskrifter og sjekklister! Skal likebehandling, innsyn og kvalitet sikrast må det vere detaljerte reglar som alle aktørar kan forholde seg til Kan ikkje oppretthalde felles forståing av normer, kulturar og erfaringar og kva som er rett og galt på tvers av store strukturar Internasjonalisering av helsetenester, legemarknaden, utdanning og migrasjon gjer regelstyringa naudsynt sett frå politikkens og administrasjonens UTSIKT

56 Trekk pusten før siste etappe - som er Sudan!

57 2,51 mill km2, 7x Norge, Afrikas største, nr 10 i verda 41 mill innb 26 føderale statar >70% fattigdom BNP 700 USD Krig i Darfur og Sør- Sudan Val i 2010

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59 Presentation of the Gezira State Family Medicine Project in Sudan UNIVERSITY OF GEZIRA, FACULTY OF MEDICINE, DEPARTMENT OF COMMUNITY MEDICINE PROPOSAL FOR AN M.Sc PROGRAM IN FAMILY MEDICINE BY COURSES AND DISSERTATION مقترح برنامج ماجستير العلوم في طب األسرة بالمقررات والبحث التكميلي

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67 WHO: What has been considered primary care in well-resourced contexts has been dangerously oversimplified in resourceconstrained settings

68 PROGRAM OBJECTIVES General objective: To graduate a family doctor capable of providing high quality health care at the primary health care level. Specific Objectives: The graduate from this Program will be fully qualified to Provide high standards and evidence based curative, preventive, promotive and rehabilitative health services. Use biopsychosocial approach in practice. Provide personal care to individuals within the family. Conduct scientific health research. Lead, plan and manage health services at the primary health care level in a team work manner. Integrate and coordinate health services to patients and families. Observe the code of professional ethics in practice and respect the community beliefs and culture.

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70 My conclusions The undergraduate curriculum is impressive, modern and with a community approach that is internationally in front and fully complying with WHO and WONCA The quality of graduates seems satisfactory, also shown by the acceptance for work Arab and Western countries Gezira has a stage of development, a level of medical care and challenges that make it adequate to think of developing primary care based on family medicine specialists The level of understanding of the foundations and usefulness of family medicine was encouraging, and is a definite prerequisite for going further with the project

71 My recommendations (I) Establish a family medicine program through the university of Gezira The speciality program should be aiming at approved specialists in family medicine in line with other specializations and specialists. The program should be based on the principles of training while in field service. At least 70% of the training should be as work as family physicians. This will supply primary care with a large group of doctors working while in training.

72 Recommendations (II) There is a need for defining the roles and tasks of the family physician in Sudan, having a new role as first contact for all people and all health problems. A modern family physician should not be doing specialist work (medical or surgical) only because of lack of resources The program should be an integrated primary care university hospital program. The integration should be secured by a specified curriculum that shows the roles of the different parts: University teaching Hospital training Primary care (in field service) training : The usefulness of training while working, the need of supervisors, the need of group based discussions and meetings

73 Recommendations (III) The teaching should be based on the most modern pedagogical principles, use of distance learning, telemedicine and skills lab training in a university environment, together with traditional clinical teaching in the health centres and in hospitals. Formal teaching through lectures should be at a modest level, while group discussions, workshops, discussions and case approaches should be emphasized. There must be established a program for teaching the teachers.

74 Last update: Go, go, go!

75 Kjære kolleger! Lykke til med møtet, vidare UTSIKT og utvikling av allmennmedisinen i Sverige! Takk for meg!