Delivering anticipatory care in primary care: Lessons from a national programme in Scotland. C O’Donnell, M Mackenzie et al Universities of Glasgow & Edinburgh, Scotland.
Transcript
Slide 1
Delivering anticipatory care in primary care: Lessons from a
national programme in Scotland. C ODonnell, M Mackenzie et al
Universities of Glasgow & Edinburgh, Scotland.
Slide 2
Burden of ill-health. The Scottish Government, 2008. Equally
Well.
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Inequalities a Scottish problem. Sridharan et al. Soc Sci Med
2007 65: 1942-52.
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Determinants of inequalities.
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Tackling inequalities. The Scottish Government, 2008. Equally
Well. Least deprived Most deprived
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Delivering for Health. Julian Tudor Hart, Glyncorrwg, Wales.
Proactive case finding, preventive interventions and regular
follow-up. Conducted during patient consultations and build on
continuity of care and knowledge of patients. Improvement in health
outcomes including 28% reduction in CHD mortality rates (over 25
years).
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Key stakeholder interviews. Interviews conducted annually in
three rounds, from late 2007 - 2009. 74 interviews. National, local
and general/family practice level. Strategic and operational
personnel: Directors & civil servants in Scottish Government.
Programme leads. Directors of Public Health. Pilot level managers.
Staff involved in service delivery. Staff in participating general
practices.
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Rationale for the programme. Programme design. 45 64 year olds.
Living in areas of greatest socioeconomic deprivation. Focus on
coronary heart disease. Delivered through family practices. Offered
a health check. Medical &/or social interventions. Why?
Reducing inequalities. Ministerial driver. Involvement of family
practices wanted by the Minister. Risk factors for CHD common to
other diseases.
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Divides and choices General practice/primary care vs health
improvement. Medical approaches vs wider social approaches.
Population-wide approach vs individual targeting. Reactive care vs
anticipatory care.
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General practice vs health improvement Not the original model
bolted onto general practice. Implications for long-term
sustainability. May widen inequalities if worried well accept more
readily. Building on previous health improvement initiatives.
Strengthening link between family practice and non-health
sectors.
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Medical vs wider social approaches. Clear tension between
medical and social models. Politicians need quick return for
effort. Focus on medical interventions more than social
interventions. Recognition that programme has to identify and
respond to behavioural and social issues in order to be a
success.
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Population approach vs individual targeting. Confusion as to
whether it should be population-level or targeted at individuals.
Different models: Offered to all in the practice age band
regardless of socioeconomic status. Offered only to those in
practice living in most deprived areas. May attract worried well.
May widen inequalities. Have to be able to justify large scale
primary prevention approach.
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Reactive vs anticipatory care. Opportunity to do things
differently. It tends to be a luxury for the NHS because were
caught up in dealing with the burden of reactive patients that we
see coming through the door. (B008, L33-35) Recognition that
patients with complex health & social needs may not be ready
for this.
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What is anticipatory care? No shared understanding or
definition of anticipatory care. I mean I suppose were, were still
struggling with what we truly are meaning by anticipatory care, and
it gets bandied about without people necessarily being concise
about what we do mean by that N013 L340-343.
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Respondents definition. Often seen in the context of
prevention. But Broader encompassing primary & secondary
prevention. Included treatment. Early detection of disease.
Anticipation of future problems - to prevent the coming tsunami of
disease.
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Conclusions. Embedding of anticipatory care approaches in
family practice raises important challenges. Clearer, shared
definitions would help. Medical and social models must be
integrated if anticipatory care is to impact on health
inequalities. Accept worried well will participate, but address
issues of targeting the hard-to-reach. Otherwise, potential to
widen inequalities. Need for short-term political gain may run
counter to the original ethos of anticipatory care.
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My colleagues. Mhairi Mackenzie, Maggie Reid, Urban Studies,
University of Glasgow. Fiona Turner, Yinging Wang, Julia Clark.
General Practice & Primary Care, University of Glasgow. Sanjeev
Sridharan, University of Toronto. Steve Platt, University of
Edinburgh.