1. RRHeal RGH Meeting Inverness 29th Sept 2016

2. The National Clinical Strategy:
Political desire for transformational change Chief Executives need for sustainability Must be evidence based Must enhance quality & be clinically credible

3. The Approach: Support & enhance Primary Care
Balance Health and Social Care
Reduce reliance on in-patient beds
Fewer in-patient units offering more specialised care
Realistic Medicine

4. Primary Care based around communities.
Expanded multi-disciplinary teams
Addressing social needs/isolation/mental illness
Focus on multi-morbidity
Remove QoF, manage polypharmacy.
Stronger emphasis on self-management, health literacy, understanding treatment burden
Understand and value patient preferences

5. Interfaces Significant challenges for IJBs Admission avoidance
Discharge delay (150,000 bed days per quarter)
Must improve to allow funding to go to Primary Care?

6. Secondary care designed round centres of excellence?
Evidence that some services should be planned on national or regional basis:
Prostate Cancer
Complex cancers
Orthopaedic example
Vascular Services
Clinical need for fewer in-patient units

7. Secondary Care based around centres of excellence:
Out-patient, diagnostics, day-case done in almost all hospitals In-patient units reduced. Emergency & Urgent care maintained Must link via clinical networks Marked staffing consequences.

8. A new Clinical Paradigm
Move beyond “Fix-it” medicine. Need to review what we do, not how efficiently we do it. Must focus on what informed, involved patients value. Seek feedback on outcomes Need for Realistic Medicine

9. Realistic Medicine Aims to add value: Reduce variation
Least invasive processes first
Manage risk proportionately
Understand limits of evidence
Avoid over-diagnosis/over-treatment
Informed patients able to express preferences
Reduce waste
Avoid medical response to social problems

10. Medieval Medicine:
Leeches & Blood letting
Trephining & …………..
Society sought out treatment from “doctors” - driven more by hope than experience and struggling to accept the inevitable limitations of our short lives.

11. Preventative Medicine: The Era of the Black Death
Flagellants believed self-punishment would atone the gods, and prevent death.
Many died from their wounds.

12. Conclusion: They were emotionally programmed to want to treat
They may have focused on interventions rather than outcomes
Emotionally driven by hope rather than experience
They may have discounted side effects
But of course we have changed now

13. Time for Realism.

14. Variation in Outcomes: Getting back home after hip fracture:
Hospitals –
a range from 30% to 65% (2015)
National change since 2012/13
44% to 52%
Outcome variation – this is a serious serious issue – this slide suggests that we need to have a serious improvement process in place

16. Guidelines: Best advice we have, but not full story
QoF started 2004

17. {Doctors generally chose less treatment for themselves than they suggest for patients.}
{Patients who are fully informed choose less treatment and have less regret}
Thjis is one of the best papers to come out of the King’s Fund ever. It collects evidence to show that doctors consistently get it wrong when they believe that they know what patients would choose. If patients are fully informed about interventions then a great ,many decide on a less interventional and more conservative approach. For example many patients with heart disease believe that stenting a narrowed coronary artery will prolong their life – when given accurate information, there is a 40+% drop in the numbers of patients who agree to progress to surgery. This sort of result is seen in many clinical situations – intervertebral disc surgery, asymptomatic AAA, hysterectomy for mennorhagia, chemotherapy, etc etc.
The philosophy of Atul Gawande’s approach becomes evident here: He has stressed in “Being Mortal” the need for doctors to ask seriously ill patients “What do you understand of your illness?”, “What matters to you?” and “What would good look like?”. He showed that patients can be helped to find better experiences of end of life care through doctors being more courageous in asking questions, and listening carefully to what patients need to know, and whattheir preferences are, based on their values

18. Appreciate Treatment Burden:

19. Need to help patients understand balance of risk and benefit
Benefit from Decision Support Aids
Can demonstrate Number Needed to Treat”
and
Aim for the least invasive intervention first

20. Conclusion NHS achieving great things, but uncertain future
Focus on Primary/Social Care
Fewer, but more specialised in-patient units
Focus on avoiding admissions/discharge delay
Realistic Medicine – focus on patient value

21. Questions?