Role of specialists in common chronic diseases
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《英国医生杂志》
1 National Primary Care Research and Development Centre, University of Manchester, Manchester M13 9DL Linda Gask linda.gask@manchester.ac.uk
Consultant care is currently available to only a small proportion of people with chronic illness. How can we enable many more people to benefit from specialist expertise?
The first shift required is a departure from being concerned only with patients who are referred to outpatient clinics. Population based care is an approach to planning and delivering care to defined populations that tries to ensure that effective interventions reach all patients who need them.4 Specialists need to consider how they can improve the quality of care for those people who don't need, or don't get, to see them and how they can ensure that those who do need to see them actually do. This is broader than simply a public health perspective; it is about taking a leadership role in planning effective clinical care for a population with the extended team across primary and secondary care. It requires thinking beyond the door of the clinic. Consultants in the United Kingdom rarely do this at present.
Designing stepped care pathways
The clinical role requires consultants to work more closely with general practitioners and specialist nurses or therapists, advising on treatment and lifestyle alterations. This will usually mean visiting the health centre, which improves the relationship across the primary-specialist interface. The consultant provides the specialist overview, being the member of the team most up to date in the specialty.
The approach differs from the consultation liaison or outreach clinics, which have had a chequered history in the NHS.15 All carers are working from the same stepped care protocol and information system and a case manager oversees the process. The key is ensuring that the consultant is used appropriately (box 1). The consultant might travel around several clinics and carry out joint consultations with the doctor or nurse and patient. Joint consultations would serve an educational as well as clinical purpose13 and could even replace the majority of traditional outpatient appointments. A specialist who values this way of working told me:
Summary box
Most people with chronic illnesses are never seen by a specialist
The specialist should have a key role in improving quality of care outside the clinic
This requires more effective bridging of the primary-specialist interface for people with chronic illness
Stepped care protocols can incorporate appropriate use of specialist expertise
In this setting, because the doc and the nurse know the patient inside out, they can bring me up to speed really quickly, I can then go in and get to the meat of what matters to the patient very early. We can also work out a whole series of things they might try, and so often what I try and end up doing is laying out some options for a variety of things over the next six months. So the patients often feel as if they get a lot out of it and the primary care team feels as if they've been supported. They've got several things they can try and they're still in control.—specialist in health maintenance organisation
The consultant has an educational role through regular meetings with staff at all levels. These meetings should provide supervision and support but also build mutual trust by acknowledging that the consultant has a lot to learn about primary care. The consultant should also take the lead in improving quality of care and getting the processes in place.16 System change takes time, diplomatic skills, effective communication, and good working relationships. Primary care teams have to adapt to having a new member, and successful collaboration requires patience and humility. People I spoke to at all levels of the care process identified various qualities required by consultants (box 2).
Conclusions
Wagner EH. The role of patient teams in chronic disease management. BMJ 2000;320: 569-72.
Dixon J, Lewis R, Rosen R, Finlayson B, Gray D. Can the NHS learn from US managed care organisations? BMJ 2004;328: 223-6.
Gask L. Powerlessness, control and complexity: the experience of family physicians in a group model HMO. Ann Fam Med 2004;2: 150-5.
Wagner EH. Population-based management of diabetes care. Patient Educ Counsel 1995;26: 225-30.
Glasgow R. A practical model of diabetes management and education. Diabetes Care 1995;18: 117-26.
Katon W, von Korff M, Lin E, Simon G. Rethinking practitioner roles in chronic illness: the specialist, primary care physician, and the practice nurse. Gen Hosp Psychiatry 2001;23: 138-44.
Aubert RE, Herman WH, Waters J, Moore W, Sutton D, Peterson BL, et al. Nurse case management to improve glycemic control in diabetic patients in a health maintenance organization. A randomised, controlled trial. Ann Intern Med 1998;29: 605-21.
Emmons KM, Rollnick S. Motivational interviewing in healthcare settings: opportunities and limitations. Am J Prev Med 2001;20: 68-74.
Wagner E. More than a case manager. Ann Intern Med 1998;129: 654-6.
Esterman AJ, Ben-Tovim DI. The Australian coordinated care trials: success or failure? Med J Aust 2002;177: 469-70.
Seal L, Dunt D, Day SE. Introducing coordinated care. 2. Evaluation of design feature and implementation processes implications for a preferred health system reform. Health Policy 2004;69: 215-38.
Gilbody S, Whitty P, Grimshaw J, Thomas R. Educational and organizational interventions to improve the management of depression in primary care: a systematic review. JAMA 2003;289: 3145-51.
McCulloch DK, Price MJ, Hindmarsh M, Wagner M. A population-based approach to diabetes management in a primary care setting: early results and lessons learned. Chronic Dis Manage 1998;1: 12-22.
Department of Health. Improving chronic disease management. www.dh.gov.uk/assetRoot/04/07/52/13/04075213.pdf (accessed 15 Dec 2004).
Bailey JJ, Black ME, Wilkin D. Specialist outreach clinics in general practice. BMJ 1994;308: 1083-6.
Bodenheimer T, Wagner E, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, part 2. JAMA 2002;288: 1909-14.(Linda Gask, professor of primary care ps)
Consultant care is currently available to only a small proportion of people with chronic illness. How can we enable many more people to benefit from specialist expertise?
The first shift required is a departure from being concerned only with patients who are referred to outpatient clinics. Population based care is an approach to planning and delivering care to defined populations that tries to ensure that effective interventions reach all patients who need them.4 Specialists need to consider how they can improve the quality of care for those people who don't need, or don't get, to see them and how they can ensure that those who do need to see them actually do. This is broader than simply a public health perspective; it is about taking a leadership role in planning effective clinical care for a population with the extended team across primary and secondary care. It requires thinking beyond the door of the clinic. Consultants in the United Kingdom rarely do this at present.
Designing stepped care pathways
The clinical role requires consultants to work more closely with general practitioners and specialist nurses or therapists, advising on treatment and lifestyle alterations. This will usually mean visiting the health centre, which improves the relationship across the primary-specialist interface. The consultant provides the specialist overview, being the member of the team most up to date in the specialty.
The approach differs from the consultation liaison or outreach clinics, which have had a chequered history in the NHS.15 All carers are working from the same stepped care protocol and information system and a case manager oversees the process. The key is ensuring that the consultant is used appropriately (box 1). The consultant might travel around several clinics and carry out joint consultations with the doctor or nurse and patient. Joint consultations would serve an educational as well as clinical purpose13 and could even replace the majority of traditional outpatient appointments. A specialist who values this way of working told me:
Summary box
Most people with chronic illnesses are never seen by a specialist
The specialist should have a key role in improving quality of care outside the clinic
This requires more effective bridging of the primary-specialist interface for people with chronic illness
Stepped care protocols can incorporate appropriate use of specialist expertise
In this setting, because the doc and the nurse know the patient inside out, they can bring me up to speed really quickly, I can then go in and get to the meat of what matters to the patient very early. We can also work out a whole series of things they might try, and so often what I try and end up doing is laying out some options for a variety of things over the next six months. So the patients often feel as if they get a lot out of it and the primary care team feels as if they've been supported. They've got several things they can try and they're still in control.—specialist in health maintenance organisation
The consultant has an educational role through regular meetings with staff at all levels. These meetings should provide supervision and support but also build mutual trust by acknowledging that the consultant has a lot to learn about primary care. The consultant should also take the lead in improving quality of care and getting the processes in place.16 System change takes time, diplomatic skills, effective communication, and good working relationships. Primary care teams have to adapt to having a new member, and successful collaboration requires patience and humility. People I spoke to at all levels of the care process identified various qualities required by consultants (box 2).
Conclusions
Wagner EH. The role of patient teams in chronic disease management. BMJ 2000;320: 569-72.
Dixon J, Lewis R, Rosen R, Finlayson B, Gray D. Can the NHS learn from US managed care organisations? BMJ 2004;328: 223-6.
Gask L. Powerlessness, control and complexity: the experience of family physicians in a group model HMO. Ann Fam Med 2004;2: 150-5.
Wagner EH. Population-based management of diabetes care. Patient Educ Counsel 1995;26: 225-30.
Glasgow R. A practical model of diabetes management and education. Diabetes Care 1995;18: 117-26.
Katon W, von Korff M, Lin E, Simon G. Rethinking practitioner roles in chronic illness: the specialist, primary care physician, and the practice nurse. Gen Hosp Psychiatry 2001;23: 138-44.
Aubert RE, Herman WH, Waters J, Moore W, Sutton D, Peterson BL, et al. Nurse case management to improve glycemic control in diabetic patients in a health maintenance organization. A randomised, controlled trial. Ann Intern Med 1998;29: 605-21.
Emmons KM, Rollnick S. Motivational interviewing in healthcare settings: opportunities and limitations. Am J Prev Med 2001;20: 68-74.
Wagner E. More than a case manager. Ann Intern Med 1998;129: 654-6.
Esterman AJ, Ben-Tovim DI. The Australian coordinated care trials: success or failure? Med J Aust 2002;177: 469-70.
Seal L, Dunt D, Day SE. Introducing coordinated care. 2. Evaluation of design feature and implementation processes implications for a preferred health system reform. Health Policy 2004;69: 215-38.
Gilbody S, Whitty P, Grimshaw J, Thomas R. Educational and organizational interventions to improve the management of depression in primary care: a systematic review. JAMA 2003;289: 3145-51.
McCulloch DK, Price MJ, Hindmarsh M, Wagner M. A population-based approach to diabetes management in a primary care setting: early results and lessons learned. Chronic Dis Manage 1998;1: 12-22.
Department of Health. Improving chronic disease management. www.dh.gov.uk/assetRoot/04/07/52/13/04075213.pdf (accessed 15 Dec 2004).
Bailey JJ, Black ME, Wilkin D. Specialist outreach clinics in general practice. BMJ 1994;308: 1083-6.
Bodenheimer T, Wagner E, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, part 2. JAMA 2002;288: 1909-14.(Linda Gask, professor of primary care ps)