We updated the title of this post to reflect the fact that our aim is to promote healthy living - physically, psychologically, and socially - and not just to diagnose and treat illness. Thanks to Anonymous for pointing this out to us in the comments section.
Many of our patients will already have noticed that we are constantly talking about 'registers'. One of the first things I look at when I open a patient's chart is the box in the top left of the screen. It's the 'disease register' list (Chronic Issues Registers). These are chronic issues that we want to prevent, screen for, and treat aggressively when we find them. For example, diabetes and asthma. Some registers are supportive - for example the Carers' Register is a list of patients who care for relatives or friends with serious health problems.
We use these registers to call patients back - usually to see our Practice Nurses for review on a regular basis. We have guidelines for each one - a series of questions, tests, or goals which will help keep our patients healthy (and, hopefully, out of the emergency department!).
The registers also help us track the quality of the care we provide to our patients. In fact, setting up chronic issues registers is the first step in any quality system. Unless we know how many diabetics we have and who they are, we can't check if we are getting their care right.
Knowing what percentage of patients we have with a disease also helps us plan our care. This is called 'prevalence data'. Every night, our computer system (EMR) counts up how many patients we have in each register and divides it by our total number of patients.
Here are our current prevalence figures for Sherwood:
You can compare them with the prevalence of illnesses in our Scottish practice here.
In Scotland, you will see from the link that you are able to compare our prevalence with that of our neighboring practices and a national average. Unfortunately, we can't show you any comparison data for our Canadian practice because we can't find any. Either no-one else is collecting this data in Canada, or they are not publishing it online. (If you know where we can get hold of this data, let us know.)
When comparing prevalences between our Canadian and Scottish patients, some points should be borne in mind. 1. The average age in our Scottish practice is unusually high. 2. We have not reviewed all of our Canadian patients yet, and in many cases are relying on self-reporting on the online registration form. For example, we only have recorded weights in our database from just over half of our patients. So the actual rate of obesity is likely to be around 25% once all our patients have been weighed.
June 18, 2010
June 12, 2010
Access, Equality, Quality, Economy: Good quality primary care for all without bankrupting the province?
The Guardian ran an article on access to family physicians in PEI.
This is part of a wider debate about the rising costs of health care, particularly as the population ages and their medical care becomes ever more complex (and costly).
There are four features of an ideal primary health care system: access, quality, equality, and economy.
In other words, we need a system that patient have easy access to, that provides good quality care, that is available equally to all, and that is affordable.
Lets look at those four topics in more detail.
Access
Unless a primary care service is accessible, it will not meet the needs of patients.
There are three parts to access:
1. how long patients wait to get on a family physician's list of patients
2. how long patients have to wait for an appointment with their family physician.
3. how long patients wait to be seen on the day of their appointment.
These three barriers to access are like a pyramid (see Figure 1 below).
You have to get past each barrier in turn.
If you don't have a family physician, then short waiting times for patients that do have one are no use to you.
Once you have a family physician, then unless you can get an appointment with your family physician, short waiting times on the day are of no use to you.
We'll look at ways to improve access in a moment, but first we need to look at our other aims to make sure these are met too.
Equality
Access to quality health care is a basic right of citizens in a civilized society. For society to be fair, access to basic rights must be equal.
It is not acceptable for people to be denied access to quality health care because of where they live, or the level of their income, or the type of job they have, or the colour of their skin, or because they don't know the right people.
Everyone should have equal, fair access to quality health care provision.
So whatever we do to improve our health care system, must met the equality test: Does this make provision of health care more or less fair?
Quality
Health care provision needs to be of high quality to be effective.
It is easy to improve access to health care cheaply by simply providing poor health care. In fact, this is exactly what New Labour in Britain did to the National Health Service over the last 15 years: they brought waiting times for specialist treatment down dramatically, but the quality of hospital care suffered as a result. This technique was referred to in the UK press as 'never mind the quality, feel the width'.
It is vital as we look at how to improve provision of health care that we look at ways that also improve - or, at the very least, maintain - quality of care.
Economy
As you might expect, over the years in my discussions with health service managers and politicians, the topic of money causes the biggest disagreements.
There are few problems with the current health care system that could not be solved with an unlimited amount of money. But sadly, there is not enough money in the world to make this a viable solution. No-one - not even the richest countries - have access to unlimited amounts of money. Canada is a rich country, but even Canada could literally spend all of it's GDP (money) on health and still not meet all possible health needs of its citizens.
Secondly, even if we had the money we don't have the doctors. The shortage of family doctors in rural areas is a world-wide problem that is getting worse. This is partly due to changes in society - the reduction in the hours doctors are willing to work, the increase in family/work balance, the increase in patient expectations - and partly due to changes in the job - medicine is much more complex and stressful than it used to be.
This is only going to get worse as the population ages.
It is important to make sure that everything we do is cost effective. The more cost effective we are, the more quality care we can provide with the money that we have.
Thankfully, this is not as difficult as it sounds, because there are lots of things we do currently that are not of any benefit to patients or may even be harmful. There are lots of cost savings to be made from better prescribing of cheaper medicines that are just as effective. There are lots of efficiency savings that can be made by making sure we have the right mix of team members doing the right jobs.
Table 1. Comparison of various models of care.
Back to Access
Which brings us back to the main point of this post: improving access.
We must solve the first access barrier - lack of access to a family physician. Until that is solved, our system will always be unfair and unequal.
We can solve that by simply increasing the number of patients that each doctor has. That is the most equitable solution as it means everyone will have access to a family physician. It is also cost effective. This has been tried in other places, but without other changes this will lead to longer waits to see a family doctor for all patients and/or a decline in quality of care. It will likely also lead to more doctor burnout, which will reduce access further in the future.
One change we can make is to differentiate more between acute illness and chronic illness. Acute (short term) illness ranges from simple coughs and colds to medical emergencies like heart attacks. Chronic (long term) illnesses are things like diabetes, chronic bronchitis, asthma and so on.
Acute illnesses can be dealt with quite effectively without having to see your own family doctor. The emergency department is the best place for medical emergencies, while the walk-in-clinic system works well for coughs and colds and other minor illness.
It is chronic illnesses (and their prevention) that can only be managed properly by your family practitioner. Or more correctly, by your family practice team. Because, the research is that patients do far better when their chronic illnesses are looked after by a good team: usually family practice nurses working with a family physician. This team is best placed to co-ordinate all the care that is needed for patients with these complex conditions.
The Solution?
So our proposed solution is:
1. Register a lot more patients so everyone has access to a family doctor.
2. Set up computerised 'registers' of patients with chronic illnesses. These patients are the ones that need access to their own family doctor's team.
3. Use computerised appointment systems to 'time limit' a certain proportion of appointments to improve access (for example, a third of appointments can't be booked until a week in advance).
4. If waiting times for appointments build up, divert acute illness (coughs and colds) to walk in clinics (emergency departments should be seeing all medical emergencies such as heart attacks and strokes).
5. Use Practice Nurses to screen for chronic diseases, look after patients with chronic illness, and educate patients on how to stay well.
6. Use computer systems to communicate and co-ordinate care better with other health care providers.
7. Computerised prescribing of medication refills to make medication reviews safer and more efficient.
8. Focus the doctors' time on what they do best: diagnosing illnesses and advising on medical treatment.
Hopefully this will come as close as is possible to meet our aims: access, equality, quality, economy.
This is part of a wider debate about the rising costs of health care, particularly as the population ages and their medical care becomes ever more complex (and costly).
There are four features of an ideal primary health care system: access, quality, equality, and economy.
In other words, we need a system that patient have easy access to, that provides good quality care, that is available equally to all, and that is affordable.
Lets look at those four topics in more detail.
Access
Unless a primary care service is accessible, it will not meet the needs of patients.
There are three parts to access:
1. how long patients wait to get on a family physician's list of patients
2. how long patients have to wait for an appointment with their family physician.
3. how long patients wait to be seen on the day of their appointment.
These three barriers to access are like a pyramid (see Figure 1 below).
If you don't have a family physician, then short waiting times for patients that do have one are no use to you.
Once you have a family physician, then unless you can get an appointment with your family physician, short waiting times on the day are of no use to you.
We'll look at ways to improve access in a moment, but first we need to look at our other aims to make sure these are met too.
Equality
Access to quality health care is a basic right of citizens in a civilized society. For society to be fair, access to basic rights must be equal.
It is not acceptable for people to be denied access to quality health care because of where they live, or the level of their income, or the type of job they have, or the colour of their skin, or because they don't know the right people.
Everyone should have equal, fair access to quality health care provision.
So whatever we do to improve our health care system, must met the equality test: Does this make provision of health care more or less fair?
Quality
Health care provision needs to be of high quality to be effective.
It is easy to improve access to health care cheaply by simply providing poor health care. In fact, this is exactly what New Labour in Britain did to the National Health Service over the last 15 years: they brought waiting times for specialist treatment down dramatically, but the quality of hospital care suffered as a result. This technique was referred to in the UK press as 'never mind the quality, feel the width'.
It is vital as we look at how to improve provision of health care that we look at ways that also improve - or, at the very least, maintain - quality of care.
Economy
As you might expect, over the years in my discussions with health service managers and politicians, the topic of money causes the biggest disagreements.
There are few problems with the current health care system that could not be solved with an unlimited amount of money. But sadly, there is not enough money in the world to make this a viable solution. No-one - not even the richest countries - have access to unlimited amounts of money. Canada is a rich country, but even Canada could literally spend all of it's GDP (money) on health and still not meet all possible health needs of its citizens.
Secondly, even if we had the money we don't have the doctors. The shortage of family doctors in rural areas is a world-wide problem that is getting worse. This is partly due to changes in society - the reduction in the hours doctors are willing to work, the increase in family/work balance, the increase in patient expectations - and partly due to changes in the job - medicine is much more complex and stressful than it used to be.
This is only going to get worse as the population ages.
It is important to make sure that everything we do is cost effective. The more cost effective we are, the more quality care we can provide with the money that we have.
Thankfully, this is not as difficult as it sounds, because there are lots of things we do currently that are not of any benefit to patients or may even be harmful. There are lots of cost savings to be made from better prescribing of cheaper medicines that are just as effective. There are lots of efficiency savings that can be made by making sure we have the right mix of team members doing the right jobs.
Table 1. Comparison of various models of care.
| Model of care | Number of patients | Appointments per week | Ratio appts/wk/patient | Cost per patient/year |
| Fee for Service | 1,500 to 2,000 | 100 to 150 | 5% to 10% | $140 |
| Salaried | 1,200 | 100 | 8% | $180 |
| Multi-disciplinary Team | 3,000 to 5,000 | 300 to 450 | 8% to 10% | $130 |
Back to Access
Which brings us back to the main point of this post: improving access.
We must solve the first access barrier - lack of access to a family physician. Until that is solved, our system will always be unfair and unequal.
We can solve that by simply increasing the number of patients that each doctor has. That is the most equitable solution as it means everyone will have access to a family physician. It is also cost effective. This has been tried in other places, but without other changes this will lead to longer waits to see a family doctor for all patients and/or a decline in quality of care. It will likely also lead to more doctor burnout, which will reduce access further in the future.
One change we can make is to differentiate more between acute illness and chronic illness. Acute (short term) illness ranges from simple coughs and colds to medical emergencies like heart attacks. Chronic (long term) illnesses are things like diabetes, chronic bronchitis, asthma and so on.
Acute illnesses can be dealt with quite effectively without having to see your own family doctor. The emergency department is the best place for medical emergencies, while the walk-in-clinic system works well for coughs and colds and other minor illness.
It is chronic illnesses (and their prevention) that can only be managed properly by your family practitioner. Or more correctly, by your family practice team. Because, the research is that patients do far better when their chronic illnesses are looked after by a good team: usually family practice nurses working with a family physician. This team is best placed to co-ordinate all the care that is needed for patients with these complex conditions.
The Solution?
So our proposed solution is:
1. Register a lot more patients so everyone has access to a family doctor.
2. Set up computerised 'registers' of patients with chronic illnesses. These patients are the ones that need access to their own family doctor's team.
3. Use computerised appointment systems to 'time limit' a certain proportion of appointments to improve access (for example, a third of appointments can't be booked until a week in advance).
4. If waiting times for appointments build up, divert acute illness (coughs and colds) to walk in clinics (emergency departments should be seeing all medical emergencies such as heart attacks and strokes).
5. Use Practice Nurses to screen for chronic diseases, look after patients with chronic illness, and educate patients on how to stay well.
6. Use computer systems to communicate and co-ordinate care better with other health care providers.
7. Computerised prescribing of medication refills to make medication reviews safer and more efficient.
8. Focus the doctors' time on what they do best: diagnosing illnesses and advising on medical treatment.
Hopefully this will come as close as is possible to meet our aims: access, equality, quality, economy.
June 9, 2010
Open Doors: a family physician for every patient in PEI?
Access. Quality. Equality. Economy. Those are our four aims in providing health care.
Now that our new offices are open, our multi-disciplinary team (four nurses, three technicians, and one doctor) is working at close to full speed.
This means that we can now see between 350 and 450 patients per week. On paper, this means we should be able to provide quality care to over 5,000 patients. We currently have just over 3,000 and we can usually see patients in 1 to 2 weeks (urgent patients within 1 to 2 days).
So we have opened our doors to new patients again. Some patients have commented that the 'number of spaces left' section is now missing from the website. This is because we've not set an upper limit on the spaces available, but instead will aim to add more staff and doctors to our 'group medical practice' as it grows over the next few years.
This is an aspiration. On paper we can move closer to it. Of course, planning and aspirations are not the same as reality. There is the risk that we will fail before we are fully 'developed' - due to illness, funding problems, etc.. However, as long as our doors stay open, everyone in PEI has access to a family physician. (Although, clearly, many are some distance from us!)
That's a fantastic situation for PEI patients.
We're going to try our best to maintain it.
Now that our new offices are open, our multi-disciplinary team (four nurses, three technicians, and one doctor) is working at close to full speed.
This means that we can now see between 350 and 450 patients per week. On paper, this means we should be able to provide quality care to over 5,000 patients. We currently have just over 3,000 and we can usually see patients in 1 to 2 weeks (urgent patients within 1 to 2 days).
So we have opened our doors to new patients again. Some patients have commented that the 'number of spaces left' section is now missing from the website. This is because we've not set an upper limit on the spaces available, but instead will aim to add more staff and doctors to our 'group medical practice' as it grows over the next few years.
This is an aspiration. On paper we can move closer to it. Of course, planning and aspirations are not the same as reality. There is the risk that we will fail before we are fully 'developed' - due to illness, funding problems, etc.. However, as long as our doors stay open, everyone in PEI has access to a family physician. (Although, clearly, many are some distance from us!)
That's a fantastic situation for PEI patients.
We're going to try our best to maintain it.
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