Challenges to Family Doctors in providing life-long care

Dr Donald LiPresident

World Organization of Family Doctors

WONCA

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Content

1. GLOBAL TRENDS IN FAMILY MEDICINE SERVICE DEVELOPMENT2. THE HONG KONG SCENRIO3. CHILD CARE4. CONTINUOUS CARE5. ELDERLY CARE6. MENTAL HEALTH7. SUPPORTING POLICIES AND HEALTHCARE FINANCING8. A NEW APPROACH – DISTRICT HEALTH CENTRES9. WAY FORWARD

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Technological, cultural, and demographicdevelopments are among the many factors thathave a considerable influence on :-

▪ how we practice Family Medicine

▪ how our value is perceived

▪ who our patients are

▪ why they present to us; and

▪ what they expect

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Being Family Doctors

We must be:

▪ engaged

▪ proactive

▪ adaptive

to keep being efficient and effective in making an observable and measurable positive difference in our communities.

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Role of a Family Doctor

“We can make, and it’s our duty to make, a huge humanitarian contribution and difference to the local and global community, because we are uniquely at the frontline of continuous and lifelongpatient-facing health services.”

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Quality Primary Medical Care

◆ Family Medicine

• Continuous, (hence life-long) comprehensive holisticcare

◆ All primary care doctors can provide a promotion andpreventive service for patients to achieve quality of lifeand well-being

◆ All primary care doctors should practice family medicine

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Mission of WONCA(World Organization of Family Doctors)

To improve the quality of life of the peoplesof the world through:

▪ defining and promoting its values,

including respect for universal

human rights and including gender

equity

▪ by fostering high standards of care

in general practice/family medicine

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WONCA WORLD EXECUTIVE 2018 - 2020

On May 19th World Family Doctor DayGREETINGS!

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“Declaration of Alma-Ata”, 1978Primary Health Care PHC for Universal Health Coverage UHC

▪ equity in access

▪ community participation

▪ effective and appropriate use of technology

▪ inter-sectorial collaboration

▪ provision of affordable and sustainable health care

Proposed five ideals as the foundation of all primary healthcare systems:

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After 40 years……

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The key role of primary care –to strengthen the long-term and sustainable development of the health care system

Global perspective ：

The Declaration of Astana, unanimously endorsed by all WHO Member States in Oct 2018, makes pledges in four key areas:

1. make bold political choices for health across all sectors;

2. build sustainable primary health care; 3. empower individuals and communities;

and 4. align stakeholder support to national

policies, strategies and plans.

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➢ 28 Jan 2019 - WONCA and WHO signed the landmark MOU during the WHO’s Executive Board meeting in Geneva - a milestone in the collaboration, leading to Universal Health Coverage.

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• The Astana Declaration and the WHO-WONCA MOUmanifests the commitment of family doctors to providingcomprehensive, people-centred, and professional primarycare services, which are crucial for achieving the ultimategoal of Universal Health Coverage.

• The MOU reinforces the commitment of the AstanaDeclaration and recognises the importance of the primaryhealth care team in providing quality and affordable servicesto people around the world.

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• The MOU aims to achieve Universal Health Coverage,strengthen medical services, and promote family medicine.Its key elements include: specialist training, curriculumdevelopment at both undergraduate and postgraduatelevels, continuous professional education and promotion ofcross-specialty collaboration.

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Role of a Family Doctor

“We are uniquely at the frontline ofcontinuous and lifelong patient-facinghealth services.”

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“The family doctor as a friendly extended member of the family.”

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Habit of Regular Primary Care visits

▪ the habit of regular primary care visits to promote ahealthy lifestyle

▪ a preventive approach to health care

▪ family-wide awareness of each other’s health

▪ long-term efficacy of self-care

It is hoped that the image of family doctors as an extended familymember can help promote:

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Patients’ Patterns

▪ become more and more media- and technology-savvy

▪ prefer the traditional practice of seeking secondaryand curative health care rather than primary andpreventive health care

▪ self-medicate directly by going to the local pharmacy

▪ tend to treat the medical consultation merely as aservice, instead of viewing the doctor as a caringlong-term health partner

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Challenges to the Family doctor

•The Hong Kong Patient- Values culture and appreciation- Doctor Shopping

•Healthcare Financing – Medical Insurance

•Understanding of Primary Care / Family Medicine /Specialists

•The present Hospital Authority system also providing Primary Care

•Working with specialists who are also providing Primary Medical Care complimenting each other through the life course:

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The Hong Kong Scenario

Primary medical care providers :

• 70% in private practice

• Experienced Grandfathers, self trained, experienced, effective

• Specialists providing primary care • Pediatricians• Geriatricians• Surgeons• Physicians• Gynecologists

• Vocationally trained Family Doctors/ General practitioners

• Family Medicine Specialists

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“RESPECT and TRUST to family physicians need to be earned and actively maintained.”

“We must show a united front to raise the profile of our profession and specialty

among patients and in society generally.”

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Cradle to Grave?

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Cradle

• Child care by Family Doctors – often neglected by Family Doctors / Not sought by parents?

• Leave it to the Pediatricians?

• Records / Data/ Growth Charts /Vaccination records

• Reluctant to stock and dispensing Pediatric dosage of medicine

• The need to treat the parent rather than the child

• The Family Doctor can however provide influence –behavior and health seeking behavior modification

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HK Reference framework for Preventive Care for Children in Primary Care Setting

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Preventive Care for Children by Family Doctors

• Knowledge

• Encouragement

• Ongoing awareness

• Show concern , periodic checking and questioning

• Making use of the consultation

• Offer advise in a friendly non-technical way

• Offer assistance in coordinating supportive services –vision, hearing, dental, dietitian, clinical psychologist , social workers, community centres, NGOs

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Immunization HK Childhood Immunisation program provides free vaccines to children in HK for 11 infectious diseases Family Doctors to provide proper information and clear myths

Encourage and check on compliance

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Child Development

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Role of Family Doctor – watching the child grow – accompanying the parentKnowledgeShow concernAttention and careBe inquisitive Be prepared to Answer questions

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Child Development

Development

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Childhood Injury Prevention

Share your KnowledgeEngagement with parentsProactively remind / discuss / educate parents

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Parent Empowerment – Promote Booklets on Health Care Tips

Show interest and Care – you as the Family Doctor is

part of the “Family”

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Continuous Care? Continued care – challenges

• Management of Acute problems

• Management of Chronic problems - NCDs

• Preparation for hospitalization

• Post Hospitalization Follow-up

• Public Private Co-operation

• Two way referral

• Supporting healthcare financing policies – The new Voluntary Health Insurance

• Health seeking behavior - Incentives

• Achieving prevention and Anticipatory care

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Public vs Private : HA GOPC

Chronic Disease Management projects

Private assess? Collaboration / Integration

Health Risk Assessment and ManagementManaging complications of Chronic Diseases:Wound Care; Continence careFall preventionMedication Management & ComplianceRespiratory Disease ManagementSmoking Counselling and Cessation

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Reference Frameworks

• http://www.fhb.gov.hk/en/press_and_publications/otherinfo/101231_reference_framework/index.html

Using management of Diabetes to illustrateneed of integratingprimary care services

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• Early Identification of People with Diabetes – Doctors Nurses

• Dietary Intervention for People with Diabetes – Doctors Dietitian

• Recommending Exercise to People with DiabetesDoctors Occupational therapist

• Glucose Control and Monitoring Nurses

• Drug Treatment for Hyperglycemia Doctors Pharmacists

A Population Approach in the Prevention and Control of Diabetes across the Life Course

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• Drug Treatment in Type 2 Diabetic Patients with HypertensionTeam – FP, Specialist, Pharmacist

• Lipid Management in Diabetic Patient Doctor, Dietitian, pharmacist

• Detecting and managing Complications

- Diabetic Nephropathy FP, Specialist

- Diabetic Eye Disease Optometrist, specialist

- Diabetic Foot Problems Podiatrist, specialist

Framework for Population Approach in the Prevention and Control of Diabetes across the Life Course

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Benefits of Integration in management of NCD

Optometrist

Podiatrists Physiotherapist

Mental Health

CommunityNursing

Nutritionist

Occupational Therapists

Social Worker

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A team approach in the Management of Diabetes Mellitus

Integrating :

Nursing services –general / community/specialized

PharmacyOccupational Therapy

PhysiotherapyOptometry

NutritionPodiatry

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Integrating Specialist Care ? Why

• Grey zone – where does Primary Care End and Specialist care begin?

• Collaboration and Dialogue

• mutual respect and communication are critical at all sites.

• Referral - 2 way traffic

• Fast track referral for collaborating GPs

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Grave?

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Population trend in Hong Kong by age groups in 2011-2039

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What influences Health in Older Age

Prof Niel J De WitJulius Centre for Health SCIENCES AND primary CareUMC Utrecht, Netherlands

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Prof Niel J De WitJulius Centre for Health SCIENCES AND primary CareUMC Utrecht, Netherlands

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Functional Capacity over the Life Course

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Reference Framework produced by the Primary Care Office of the Department of Health of Hong Kong September 2017

Core document • Evidence-based recommendations according to the

conceptual model for preventive care of older adults in primary care settings

Modules• Elaboration of health domains in the preventive care for older

adults in primary care setting • Modules

• Health assessment• Falls• Dental health care• Visual impairment• Cognitive impairment

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Health Assessment of the Elderly

Cue cards for doctors –a quick reference of the

functional assessment tools

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Poster for patient empowerment

Definite role for the Family DoctorThe trusted relationshipThe accepted advise

Visual Impairment

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Initial evaluation by Family Doctor and referral as necessaryAwarenessAssociated problems – family support , home arrangement , safety, accident prevention

Falls in Elderly

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Time consuming but worthwhileDemonstrate care and concernA real life hazardNot to forget possibility of osteoporosis and fragile bonesAssociate with life style adviseFamily Support

Cognitive Impairment

Role of Family Doctor:Awareness / proactive discussion with familyProvide InformationAssessmentWork with GeriatricianPromote family support - stimulation

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Department of Health Elderly Services

The Elderly Health Service aims to enhance primary health care for the elderly, improve their self-care ability, encourage healthy living and strengthen family and carers support so as to minimize illness and disability.

Elderly Health Centers provide clinic service to elders using multi-disciplinary approach with family medicine perspective.

Out-reaching Health ServiceThe Visiting Health Teams outreach into the community and residential care settings to deliver health promotion programs so as to optimize the health of the elderlyBy adopting the train-the-trainer approach, Visiting Health Teams provide training programs to carers to enhance their health knowledge and skills in caring for the elderly.

In addition, the teams also carry out annual influenza vaccination for institutionalized elders.

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Towards End of Life

Preparing for end of life

Advanced directives

Certification

Power of Attorney

Wills

Integrating End of Life Services in the community setting

• Not necessary in Hospitals

• Hospice care

• Certification by Family Doctor

• Coroner's role

Medical Social Integration

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WHO ADVOCATE INTEGRATION OF MENTAL HEALTH INTO PRIMARY CARE• Multi-morbidity is a common phenomenon in primary care• Providing preventive interventions in the primary care setting

may improve early detection and treatment of mental health problems, especially for people with multiple chronic conditions who are at a higher risk for developing mental health problems.

• The generalist primary care providers can also address mental, physical and social aspects of care at the same time, addressing mental health symptoms in the context of social life stress and distress in patients using the bio-psycho-social model rather than strictly adhering to the medical model.

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• Medically unexplained symptoms (MUS) are one of the common presentations in primary care

• Many of these patients also suffer from mental health problems and it makes primary care the ideal setting to treat their co morbid mental health problems.

• Patients often have continuing relationships with their primary care providers, treating mental health problems in primary care may make it less stigmatizing for patients and the long-term relationship with primary care providers may make patients more willing to disclose their mental health issues to their primary care providers.

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WHO ADVOCATE INTEGRATION OF MENTAL HEALTH INTO PRIMARY CARE

Integrating Mental Health

• Train Family Doctors / General Practitioners in community mental health.

Support funding for scientific research related to the impact and effectiveness of integrated health care and the contributions of psychologists as members of these teams.

Integrate mental and behavioral health care into primary care and other health care services for persons across the lifespan, with psychologists recognized as vital members of interdisciplinary health care teams.

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Healthcare financing

Behavior change of providers, end-users and administrators

Patient Culture – health seeking behavior

Values system / appreciation

Mismatch of Expectations

Bureaucracy - Stewardship

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Challenges to Family Doctors in providing life-long care in Hong Kong

Influence of Medical Insurance in Hong Kong

• Preventive care not included in most private medical

insurances

• Ancillary services e.g. physiotherapy covered but:

• Pre-existing diseases / chronic diseases /Co-morbidities not

covered

• Anything “mental” not covered

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A solution?

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Healthcare Voucher

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From 2014, the Scheme has been converted from a pilot project into a recurrent programme

and the annual voucher amount has also been increased to $2,000.

Eligible elders could continue to carry forward and accumulate unspent vouchers, subject to

a ceiling of $4,000 to encourage elders to make good use of the vouchers for primary care

services including both curative and preventive care

To alleviate the burden of medical expenses on the elderly and their families and to enhance

health promotion and primary care, the Government has lowered the eligibility age for the

Scheme from 70 to 65 with effect from 1 July 2017.

In 2018, apart from the annual voucher amount of $2,000, each eligible elder is also

provided with an additional voucher amount of $1,000 on a one-off basis on 8 June. With

effect from the same day, the accumulation limit of the vouchers has been increased to

$5,000 as a regular measure.

HA General Out-patient Clinic Public-Private Partnership Program (GOPC PPP)

• a PPP model for the delivery of primary care service and promote the family-doctor concept in the community. Delivered by Private Practitioners.

• patients suffering from specific chronic diseases such as Diabetes and Hypertension with stable medical conditions and in-need of long-term follow-up treatment at GOPCs are invited to join voluntarily at the same fee they currently pay for GOPC services.

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Public Private Partnership Challenges:

Enhancement –Not just disease orientated – Holistic Care –maximizing the consultation process

Patient Culture – health seeking behavior – ?modification

Communication - eHealth record

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Way Forward –Primary Healthcare development –District Health Centre

In her 2017 Policy Address, the Chief Executive directed that, to further illustrate the effectiveness of medical-social collaboration, the Food and Health Bureau (FHB) should set up a District Health Centre (DHC) with a brand new operation mode in Kwai Tsing District .

FHB has established the Steering Committee on Primary Healthcare Development in November 2017, to formulate the development strategy and devise a blueprint for primary healthcare services

FHB has also established the Working Group on DHC Pilot Project in Kwai Tsing District, to provide advice on the planning, implementation and evaluation of the DHC pilot project.

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Equipping community based doctors with more supportA team care approachSubsidize allied medical servicesProviding comprehensive holistic careKeeping patients away from hospitalsAvoid overload of Hospital Authority services

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Way Forward –Primary Healthcare development –District Health Centre

History - Evolution

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Promoting Teamwork – Multidisciplinary Primary CareOn site ancillary service supportEngaging private GP /FP in the Community Health Care Centers in Hong Kong

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History - Evolution

How to engage GPsTin Shiu Wai network

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History - Evolution

Target focus of services at the future District Health Centers

Obesity – Anticipatory care, prevention, management

Chronic Disease Management with holistic approach Screening /

multidisciplinary team approach-

Diabetes Mellitus

Hypertension

Musculoskeletal – coordinate physio and occupational therapy

Low back pain, Osteoarthritis of knee

Fracture hip – rehabilitation, follow-up

Rehabilitation – Post Specialist Intervention, prevention of

recurrence, continued care , carer training coordinating

multidisciplinary team care

Stroke , Coronary artery disease

Good practice – avoiding polypharmacy

Lifestyle modification – Smoking Cessation, Exercise Prescription,

Diet advice

Skills – Motivational Interviewing

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Present Allied Health in HA

AudiologyClinical PsychologyDieteticsOccupational Therapy (Physical)Occupational Therapy (Psychiatric)PhysiotherapyPodiatryProsthetic & OrthoticSpeech Therapy

Referral systemfrom Private Practitioners

Integrate servicesinto DHC?

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Prevailing charges of Private Ancillary Primary Care Services

Physiotherapist HKD 500 per hr up

Occupational therapist HKD 600 per hr up

Optometrist HKD 500 per exam up

Dietitian HKD 600 per consult up

Private Nursing HKD 800 per 8 hour shift up

Clinical Psychologist HKD 1200 per hour up

GOPD HKD 45G P consultation HKD 250 including medicine

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• Day Hospital- geriatric, psychiatric ambulatory care

• Community Medical Service

• Community Nursing, geriatric assessment, psycho geriatric, community psychiatry, community psychiatric nursing

• Smoking counseling and Cessation

• General Infirmary Service – higher dependency beyond those residential sectors provided by social welfare

• E.A.S.Y program – Early Assessment Service for Young People with Early Psychosis)

Medical Social IntegrationIntegrate services into DHC as part of primary care

Other HA community services

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Marketing and Social Marketing Campaignsto promote the District Health Centres

Major influences are often considered

▪ the medium of communication

▪ key opinion leaders

▪ community outreach

▪ social networks

▪ in-group leaders or champions

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Behavioral change of the public and the providers

Personal Process involved in uptake

▪ having knowledge of something new

▪ being persuaded by it

▪ deciding to act on it or not

▪ implementing that decision

▪ confirming that decision so as to continue its uptake or rejection

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The first step of any social change is of course

“ AWARENESS "

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Role of Hong Kong College of Family Physicians

▪ continued research to guide policy and best practices, andhelp plan for the future

▪ educate Hong Kong citizens on whom and when to contactfor medical and health services for primary care

▪ develop programmes to provide continuing care with theHospital Authority after hospitalization

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“HKCFP is associated with WONCA, which is keen to coordinate a global cost-

effective response plan for primary health care.”

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“The Contribution of Family Medicine to Improving Health Systems”, WONCA

It comprehensively describes our discipline’sroadmap.

▪ starting with a rationale

▪ setting a goal

▪ foreseeing roadblocks

▪ getting ready for action

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“Once qualified, we cannot be complacent, storage vessels of knowledge and wisdom.”

CHANGE is the only constant thing.

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keep making a world of difference in your journey in Family Medicine

▪ be ambassadors and leaders in our unique, exciting and ever-evolving specialty of Family Medicine

▪ keep learning ▪ stay aware of and adopt to our environment ▪ stay resilient

You are urged to:

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