1. F R A G M E N T A T I O N

2. FRAGMENTATION
Dysfunctional consultations
Discontinuity
Poor coordination
Gaps in coverage

3. Patients and caregivers are often put under
enormous demands by health care systems
Frances Mair, Carl May
Thinking about the burden of treatment
BMJ 2014;349:g6680 doi: /bmj.g6680 (10th November 2014)

4. DEFINITIONS OF MUTLIMORBIDITY
Two or more conditions
The number, severity and complexity
of health and social problems
within families and households
When sorrows come, they come not single spies
but in battalions
HAMLET, William Shakespeare

5. HEALTH CARE AS A PINBALL MACHINE

6. FIXING IT FOR PATIENTS
WHO ARE FLOUNDERING
BETWEEN DYSFUNCTIONAL,
FRAGMENTED, SERVICES

7. INTRINSIC FEATURES OF GENERAL PRACTICE
Contact
Coverage
Continuity
Coordination
Flexibility
Relationships
Trust

8. A COUNTRY DOCTOR

9. INVENTING THE WHEEL INTEGRATED CARE DEPENDS ON MULTIPLE RELATIONSHIPS
HUB
Contact
Coverage
Continuity
Comprehensive
Coordinated
Flexibility
Relationships
Trust
Leadership
SPOKES + RIMS
Keep Well
Child Health
Elderly
Mental Health
Addictions
Community Care
Secondary Care
Voluntary sector
Local Communities
INTEGRATED CARE DEPENDS ON MULTIPLE RELATIONSHIPS

10. Health practitioners need to ask
not only “What do I do?”
but also “What am I part of?”
Don Berwick
Head of US Medicare and Medicaid

11. A NEW BUILDING PROGRAMME FOR INTEGRATED CARE PATIENT STORIES
LOCAL HEALTH SYSTEMS
MACHINES THAT DO THE WORK OF TWO MEN

12. BUILDING PRODUCTIVE LOCAL SYSTEMS
CREATING A SOCIAL REVOLUTION IN HEALTH CARE

13. RESOURCE POOR PEOPLE RICH RESOURCE RICH PEOPLE POOR
LEADERSHIP OF HUMAN RESOURCES

14. THE COLLABORATION LADDER
Involving joint working between two potential partners
0 Never heard of each other
Have heard but have had no contact
Contact but no relationship
Relationship between named individuals
Joint review and planning

15. MESSAGE FROM THE DEEP END Patients need referral services which are :-
Local
Quick
Familiar
Attached workers who will work flexibly
and quickly according to the needs
of patients and practices
“your problem is our problem”
A machine that does the work of two men
but takes one person to work it
Strengthening the generalist function

16. BY POWERFUL BY CLEVER
PEOPLE ? PEOPLE ?
LEADERSHIP
FOR INTEGRATED CARE
BY STEETWISE BY THE

17. LEARNING BY TRIAL AND ERROR
SPOCK to KIRK : “It’s not logical, captain”

18. A LEARNING ORGANISATION
Committed to the principle :
that “the best anywhere should become the “standard everywhere”
SHARING
Knowledge
Information
Evidence
Experience
Values

19. ESSENTIAL INGREDIENTS OF GENERAL PRACTICE
Adequate consultation time
Efficient team working
High quality record and communication systems
Efficient interface with patients (reception, telephone, appointment system etc)
Efficient referral systems to primary, secondary and community care,
and community resources
Adequate administrative, nursing and pharmacy support
Professional, collegiate support
Protected time for review and learning

20. ATTRIBUTES REQUIRED OF DEEP END PRACTITIONERS
Ability to engage productively, initially and over the long term, with patients
lacking health literacy and skills for self help and self management
Competence and experience in dealing with prevalent problems, including drug
and alcohol misuse, vulnerable families, asylum seekers and migrants, poverty
and welfare benefits, previous sexual abuse, homelessness and complex multimorbidity
Competence and pragmatism in the application of evidence-based medicine, little of which
is based on studies of patients in deprived areas.
Ability to remain optimistic, enthusiastic and engaged, in the face of multiple health
and other problems presented in high volume.
Ability to work productively with colleagues, within the primary care team, with other services
in primary and secondary care and with community resources for health
Commitment to the development of general practice as the hub of local health systems
Collegiate working within local clusters of general practices

21. DISCRETIONARY ASPECTS OF GENERAL PRACTICE
How broadly to identify the problems that general practice can help (e.g. the medical model
or more widely).
How high to “set the bar”
in terms of the short, medium and long term objectives of patient care
The length of a normal working day (with average resources, practices can only increase the
numbers of patients seen by shortening consultations or lengthening the working day)
The number and type of practice staff to employ
Whether to provide extra-contractual letters for patients seeking support for benefit
applications and appeals.
Whether to invest time in developing links with local community resources for health.
Whether to take part in optional activities, including teaching, training, research
or development projects
Whether to work with other practices
Whether to pursue a leadership role in representing general practitioners
Whether to adopt a leadership role in developing the local health system
Whether to take part in advocacy, fighting against the conditions and policies which cause
poor health in patients