The future of hospital medicine

RCPE Regional Symposium Midlands 3rd May 2017

The future of hospital medicine: A view from a specialist valuing General (Internal) Medicine Dr Rahul Mukherjee www.rationalmedicine.net

The future is not a place like the Isle of Wight awaiting our arrival. It is more like the Great Western Railway, something that we have to imagine, design and build. If we do not build it other people will.

Sir Muir Gray, director, National Knowledge Service and chief knowledge officer to the NHS (2010)


Future physician Changing doctors in changing times Report of a Working Party London : RCP, 2010

The Future Physician


The context • “NHS Audit: Big Spender, Unwise Spender,” The Economist, September 13, 2007. – The growth in health-care spending in the rich countries of the world regularly outpaces the growth of the overall economy – The dramatically increased cost has not been offset by improved productivity and/or health outcomes – A proportion of health care consumed seems to be driven by physician and hospital supply, not patient need or demand (which is why QIPP is possible) RCPE Regional Symposium Midlands 3rd May 2017


The context Decisions of Value • The culture of stewardship • Moving forward from the concept of quality to value • “More of the same is not the answer. What we need is a new paradigm – a paradigm on value.” RCPE Regional Symposium Midlands 3rd May 2017

The context: Moving from the “Quality” era to the “Value” era


Building the future: Moving from the “Quality” era to the “Value” era • Curbing supply-driven growth / Combating DiseaseMongering

• Addressing Co-morbidities / Doing better General (Internal) Medicine • (Disruptive) Innovation – developing facilitated rational medicine networks and a Manifestation-based approach


Building the future Curbing supply-driven growth / Combating Disease Mongering

Disease Mongering • Definition: the selling of sickness that widens the boundaries of illness and grows the markets for those who sell and deliver treatments – Payer L (1987) How to Avoid Hysterectomy. New York: Pantheon Books. – Payer L (1992) Disease-mongers: How doctors, drug companies, and insurers are making you feel sick. New York: Wiley and Sons.

– Moynihan R, Henry D (2006) The Fight against Disease Mongering: Generating Knowledge for Action. PLoS Med 3(4): e191. doi:10.1371/journal.pmed.0030191 RCPE Regional Symposium Midlands 3rd May 2017

Disease Mongering Examples •

COPD : Flow limitation and regulation of functional residual capacity during exercise in a physically active aging population. Am Rev Respir Dis 1991;143:960–967.

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Medicine Goes to School: Teachers as Sickness Brokers for ADHD, Christine B Phillips, PLOS Medicine, 11 April 2006.

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Bigger and better: How (a Pharma company) redefined erectile dysfunction. PLoS Med 3: e132. doi: 10.1371/journal.pmed.0030132.

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Female sexual dysfunction: A case study of disease mongering and activist resistance. PLoS Med 3(4): e178. doi: 10.1371/journal.pmed.0030178.

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The Latest Mania: Selling Bipolar Disorder, David Healy, PLOS Medicine, 11 April 2006.

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(Dementia and) Cholinesterase Inhibitors: Drugs Looking for a Disease?, Marina Maggini, Nicola Vanacore, Roberto Raschetti; PLOS Medicine, 11 April 2006. RCPE Regional Symposium Midlands 3rd May 2017

Building the future: The global move towards Rational Medicine










Building the future Addressing Co-morbidities / Doing better General (Internal) Medicine

Addressing Co-morbidities / Doing better General (Internal) Medicine • A survey covering 1.75 million people showed that

– the majority of people over 65 have two or more LTCs – the majority over 75 have three or more, and more people have two or more conditions than one • [The Scottish School of Primary Care’s Multimorbidity Research Programme, 2011]

• £66 billion out of the NHS’s £110 billion is spent on managing people with LTCs (mostly poorly) RCPE Regional Symposium Midlands 3rd May 2017

Addressing Co-morbidities / Doing better General (Internal) Medicine •

The current medical education system is one of specialisms that look after a person's body parts not the person as a whole. • There is a gulf between the needs of the patients driving the system and the education of clinicians to meet that demand, but it’s changing [Shape of Training GMC document] • Applying multiple body parts guidelines and standards to a person with multiple problems misses the point and creates clinical variance and uncertainty. [Oldham J. BMJ 2013;347:f6716 doi: 10.1136/bmj.f6716]


Addressing Co-morbidities / Doing better General (Internal) Medicine • People with long term conditions now account for 70% of cost and activity in the healthcare system – Department of Health. Long term conditions strategy. http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Healthcar e/Longtermconditions/DH_064569

• As more standards are created (and lobbied for by special interests), fewer can be implemented or are relevant to the multimorbid patient population. – For example, following the guidelines for control of hypertension may worsen someone’s coexisting renal disease. RCPE Regional Symposium Midlands 3rd May 2017

Practical example: Co-morbidities in COPD • Three-quarters of severe COPD patients die in the hospital. – Respiratory failure is the leading cause of death, but, overall, accounted for only one-third of the total number of deaths – Cardiovascular causes, pulmonary infection, pulmonary embolism, lung cancer and other cancers account for the remaining two-thirds of the deaths • Sin DD, Anthonisen NR, Soriano JB, Agusti AG. Mortality in COPD: role of co-morbidities. Eur Respir J 2006; 28: 1245–1257. RCPE Regional Symposium Midlands 3rd May 2017

Practical example: Co-morbidities in COPD • Only 19% of patients with chronic obstructive pulmonary disease have no comorbidities. • Nevertheless, nearly all quality standards and guidelines for this condition are configured as if the disease is the only one that needs considering! – Ioannidis JPA. Why most published research findings are false. PLoS Med 2005;2: e124.5 RCPE Regional Symposium Midlands 3rd May 2017

Practical example: Co-morbidities in COPD • Of all hospital admissions with “Exacerbation of COPD” in an acute medical take, nearly one-third have heart failure – Castle L, Azzopardi L, Bhattacharya M, Baverstock M, Worrall L, Mukherjee R. Alternative primary diagnoses are a major challenge in the management of Chronic Obstructive Pulmonary Disease (COPD) exacerbations. American Journal of Respiratory and Critical Care Medicine 2009; 179: A1516. RCPE Regional Symposium Midlands 3rd May 2017

Building the future Innovation – developing facilitated rational medicine networks on a Manifestation-based approach

Innovation – why? • The disease burden and the requirements of patients in 2015 are very different from those of patients in 1948

• Broadly, the main challenge in 1948 was infectious disease; now it is long term conditions • Yet a doctor or nurse of 1948 walking into a hospital or general practice today would find more points of familiarity in the way they are organised, than not

• ‘The 65-year long culture of “it’s the way we do things around here” is entrenched.’ [Oldham J. BMJ 2013;347:f6716 doi: 10.1136/bmj.f6716] RCPE Regional Symposium Midlands 3rd May 2017

Specialty based Solution Shops


Specialty based Value-Adding Process


But what about…


Facilitated Networks & Specialty-based Solution shops /VAP

Facilitated Networks

Solution shops/VAP

– Make a profit by keeping people well in the community

– SS/VAP models make profit when people are sick

– Are based on a Manifestationbased approach to illness (e.g. dyspnoea, chest pain, etc.)

– Are based on a medical text book chapter approach (e.g. cardiology, neurology, etc.)

– Don’t medicalise care coordination (keeping costs low)

– Unsustainable for the care of most behaviour-dependent long term conditions

The future: Building Healthier Lives through blending Facilitated Networks with Solution shops/VAP s– managing the demand on solution shops by Facilitated Networks RCPE Regional Symposium Midlands 3rd May 2017

Integrated Model for Multiple LTC management – Moving from the “Quality” era to the “Value” era Solution shops and Specialty-based VAC

•Drives costs upwards •Promotes “gaming” around targets •Inevitable in a Gatekeeping system where GPs are forced to see people with LTCs repeatedly until they are referred to hospital, often via ambulance

Specialistled Care

GP / A&E

•The cost bubble of acute hospital care for LTCs keeps inflating

Self Care Courtesy: Dr Hugh Rayner – BEN PCT QIPP proposal 2010


Facilitated rational medicine networks •By focusing on self care, there is an interest in treating people at an early stage •Surveillance to prevent escalation of conditions requiring e.g. emergency admissions, costly CHC packages •Driving care downwards allows specialist care to become more effective – allows them to “chew the bubble gum”

•“Getting paid for keeping people well in the community”

“The future is already here — it's just not very evenly distributed...” -William Gibson


“The future is …..starting to become ‘Google-able’….....


The future is …..starting to become ‘Google-able’….....


The key challenge of co-creating a sustainable future (as climate scientists will tell you….)

RCPE Regional Symposium Midlands 3rd May 2017: Thank

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