What do consumers value?

In a nutshell, what do consumers value in health care?

Well, over the years consumers have told us this:

• spend enough time during my consultation to listen, talk and explain things to me
• explain things to me in a way I can understand
• encourage me to ask questions and does their best to answer them
• give me enough information about my condition
• give me enough information about my treatment options
• include me in decisions about my treatment options
• explain the purpose of tests and treatment in a way that I understand
• explain the results of diagnostic tests in a way that I understand
• support me to self-manage my health

Health Pathways for the ACT

On Monday 7 April I attended a joint workshop with ACT Health an ACT Medicare Local on Health Pathways. Eleanor Kerdo and Katrina, a consumer representative with HCCA, also participated.

Leanne Wells (CEO, ACT Medicare Local) formally opened the workshop and provided a brief  introduction of healthpathways, stating that it is an important collaboration between ACT Health and ACTML. Health pathways is a powerful platform to improve services and outcomes for consumers and they see it as an opportunity to develop pathways that put the patient at the centre of care and aspects of the system that need to be improved and enhanced. 

Rosemary O’Donnell (Executive Director Division of Medicine, ACT Health)  reflected on initial introduction to healthpathways as an exciting opportunity. She sees that this is a framework to enhance the patient journey through the system so that it is as seamless as possible. Rosemary commented that there is a large volume of medical services, including people living with chronic disease, and see that there are opportunities for improvement.

Ian Anderson – Streamliners NZ – Canterbury Health System, was the facilitator for the day. 

The idea of HealthPathways grew out of necessity in Christchurch, NZ. Christchurch is similar to Canberra: urban population of 400,000 people, one major tertiary hospital, catchment of 500,000.

In 2006 the Canterbury District Health Board introduced a new approach to working on problems. This involved new language and terminology, and collaborative approach across the system. By 2010 the new approach was starting to reveal results and improvements which resulted in better outcomes for patients. In 2011 Hunter New England asked about their work and they adopted aspects of their ways of working. They have shared their experience with other Australian districts. There are now 12 entities (Medicare Locals and & Local Hospital Networks) in Australia using elements of Health Pathways and six entities in NZ. In total about 10 million patients across Australia and NZ are part of this.

Three main themes:

• The environment and creating fertile ground for collaboration and service improvement
• The detail of service improvement, running work groups and getting change
• The pathways: these are enablers of service change. They reduce variation in the system and improve outcomes

Ultimately this is all about improving services. In order to achieve sustainable change you need all three of these elements. Thee Canterbury story is a classic demonstration of what is possible when managers have a vision and trust clinicians to be involved in bringing about change.

There was a presentation from Carolyn Gullery, the General Manager of Planning and Funding for Canterbury health system, who was one of the prime drivers of change. This was the presentation she made at the ACI in 2013. (20 min video). It is not online but there is a long video (over an hour) online.

Gullery describes the burning platform, with 1 in 5 people over the age of 65, and by 2020 this will grow to be 1 in 3. There is growing demand, with increased admissions to hospital and increased waiting times. If there was not change there would be a need for many more GPs, another tertiary hospital, another 6000 people in the workforce, and another 2000 nursing home beds. Obviously unachievable and not sustainable.

Graphic of Canterbury health system: Connected system, shared vision. One of the elements that appeals to me is that the work was based on a premise that you shouldn’t be in a hospital if you don’t need to be there. A key measure is not to waste people’s time, both patients and clinical staff. At the core of their work is the belief that most people do the right thing if the system enables them.

A collaborative way of working and it was led by clinicians. They had to bring about a big change. They could not wait for incremental change. 

The full story of the transformation as well as the journey they took is available online on the Kings Fund website.

Darlene Cox

Executive Director

Forum with health care consumers to discuss the ACT Chronic Disease Strategy

In recognition of the critical importance of effective chronic disease management, the ACT Government Health Directorate is developing a new ACT Chronic Disease Strategy, which will further develop the previous ACT Chronic Disease Strategy 2008-2011.  The strategy will explain how chronic disease care will be managed in the ACT community into the future.   

The prevalence of chronic diseases throughout the world is increasing significantly.  Effective chronic disease management requires working in partnership across a range of sectors, including consumers and community members, all levels of government , the private sector and non-government organisations.  It also means that consumers are supported in learning about the health and community services that are available to us.

So much of chronic disease management happens outside of the system.  We need a broad-based approach to this, including private and public providers of services, as well as services provided by non-government, community-based organisations (eg community transport, home help).  The development of the new ACT Chronic Disease Strategy requires wide consultation, and we are pleased to see that the Government is planning meetings with key stakeholders, consultative fora and a longer timeframe (6 weeks) to consult on the draft Strategy.  

Chronic conditions not only compromise our health and well-being, but can also have a significant impact on our family and friends, our capacity to be active in the community, as well as earning an income. 

Consumers need support to navigate the way through the wriggles and turns, and over the hurdles that occur in our health system.

On 28 February, Health Care Consumers Association hosted one of the first of these consultative fora.  The session was facilitated by Cathie O’Neill, a senior consultant specialising in the healthcare sector and engaged by the ACT Health Directorate to draft the Chronic Disease Strategy.

This post summarises specific areas which consumers wanted felt strongly about and which they wished to see addressed in more detail in the strategy.  

These included:

Chronic disease management outside the ACT Health Directorate (ACT HD):  an explanation of how ACT HD will promote the management of chronic disease within the community in the frequent circumstances when it falls outside the formal ACT HD system.

Advanced care and residential care directives: currently some consumers feel that despite having signed a care directive, their wishes may not always be respected because clinicians fear possible litigation.  

Links between Calvary Hospital and The Canberra Hospital: Ambulatory and outpatients: the strategy must address equity issues between the two hospitals in respect of referral for ambulatory services.  It needs to specify the number of patients at Calvary whose only continuity of care can be provided through referral back to ACT Health at The Canberra Hospital and outline a solution to address this “gap” in the system.

Diabetes: the Diabetes Strategy was still incomplete.  The Diabetes “Buddy” scheme appeared to have faded out.  Consumers wanted to know if there is a strategy to re-establish this excellent initiative?

Community Partners and Support Services: the invaluable services these groups provide need to be highlighted and formally recognised.  Many of these groups are actively supporting ACT HD to deliver its health programs and initiatives, but most lack funding, are under-resourced and much of the assistance they provide is not formally recognised. It is also felt that the HD ACT should do more to assist these Support Groups by advertising their services to the general community.  There is also a need to provide funding to educate GPs about community support services. 

Recognition of, and respect for, complementary medicine:  complementary medicine is extremely important and helpful.  However, services such as meditation, yoga and relaxation are only briefly touched upon in consultation with clinical staff.  This is an area which needs far more prominence and development, concentrating on specific areas of treatment.  

Listening to the patient’s story: getting the message across:  once qualified, clinicians often focus merely on treating a condition, rather than understanding and listening to the patient’s story. This should be used as an education tool right from the start; if medical students could be educated to improve, and understand the importance of, communication skills, this would be hugely beneficial to both patients and the medical profession as a whole.  It is also a low cost, effective solution to an ongoing problem.

Cross-referencing between health services: it is important that those living with a chronic disease are permanently recognised on admission to hospital; eg a system indicating “this is a chronic disease-registered patient”.  Currently, those with chronic conditions are only placed on a chronic disease register once they have been admitted to hospital several times; and they are eventually removed from the register, if they do not present at hospital again within a certain timeframe.  It is important that clinicians always recognise patients with chronic conditions, even when they have been admitted for treatments unrelated to their condition. 

Web-map for linking all relevant services:  there is an urgent need for a web-based effective “one-stop shop”providing details of all services available for those living with chronic conditions.  This discussion highlights the need for a comprehensive and current Health Services Directory that extends beyond services provided by ACT HD; many of the group were unaware of its existence.

Terminology to encompass “chronic disease”: people with chronic disease don’t think of themselves as sick on a day-to-day basis, because they live with the disease all the time; they would consider themselves to be “sick” if they have a flare-up of the condition.  It is also inappropriate to describe people as “sufferers” of a particular condition or disease, because, again, most do not consider themselves to be suffering from day to day.  “Living with a chronic condition” is an appropriate description.

Carers: play a vital role and must be included in the strategy.

Social workers: in many cases, social workers are too focussed on a narrow field.  They are often anxious to get people out of hospital and back home, without taking into account the patient’s family situation and pain management plan.  

Public holidays and weekends: it is important that the strategy explains how access to services will be handled during out of hours.  For example, oxygen services close down and the BOC emergency services are only able to cater for deliveries – they cannot, for example, cope with repairs or spare parts.  This puts consumers at risk.

Cross-border health issues:  the needs of those diagnosed in different health areas must be addressed – ie the strategy must include support for those living in NSW and accessing services in the ACT.

Discharge from hospital to home: it is concerning that many people, especially the elderly, are discharged from hospital without having the necessary support at home to cope with their condition.  A system needed to be implemented whereby patients could be monitored after leaving hospital to ensure they were being properly looked after.  

Secondary prevention:  consumers need quick and efficient access to advice on early prevention of chronic disease.  Currently there is room for efficiencies in this area – early treatment and prevention will offer huge savings.  Access to appropriate, timely treatment is needed – prevention is key.  For example COPD courses should be available for people before they contract the disease, rather than after they have been diagnosed.

Financial courses:  for many people with chronic disease, financial costs for treatment can be the “final straw”, adding yet another mental burden to their already stressful situation.  Mental problems caused by financial stress often exacerbate the physical condition.  Making people aware of their financial entitlements is important; this could be achieved through sponsorship with one or more financial services organisations.

Consistent case management: often you are your own case manager, but this is a complex task when you are dealing with declining health functions.  People need to be empowered and need an advocate.  It is important to have continuity – for example, having one case manager, rather than two or more, is likely to deliver a more effective outcome.

Community based Chronic Care Nurses and Nurse Practitioners: there is a strong need for nurse practitioners to coordinate care with other health professionals and a need for community-based Chronic Care nurses within the ACT.

Homogenous system: currently the system is not homogenous and the strategy must identify a plan to allow all stakeholders to communicate effectively to deliver a seamless and efficient service.  GPs and specialists are central to the strategy’s success.

The group agreed on the Draft Commitment Goals, which state:

“In the ACT we are all working together to ensure any person with a diagnosed chronic condition:

• Does not have to repeat their story unnecessarily

• Has a management plan, which supports self-management and contains goals for improvement and actions to take for acute or chronic events

• Is aware of relevant support options and how to access them

• Has their care proactively coordinated and managed

• Understands their need for, and adopts, secondary prevention

• Receives the best care, in the best place, at the best time

• Is supported by a system that is patient-centred, high quality and evidence-informed.”

Consumers will have the opportunity to provide more input to the strategy at “The Future of Chronic Disease Care in the ACT” forum on 16 March. 

Karen Jameson

Policy Officer

Consumer experiences of self managing chronic conditions

In August HCCA facilitated a workshop of around 50 consumers on behalf of the ACT Division of General Practice (ACTDGP). This workshop is part of Interprofessional Learning Project currently underway involving ANU and the ACTDGP.

Consumers were asked specifically about what helps them to self management their chronic conditions and what barriers they encounter in their self management. Participants worked in table groups to share their experiences and document their ideas.










A number of speakers also gave presentations to participants.

Russell McGowan (Pictured) talked about the national level reform in chronic conditions and also talked about his involvement with the Consumers Health Forum project on developing resources to support people to self manage their chronic conditions

Judy Stone, told the participants about the Interprofessional Learning programs currently underway in ACT Health

Other speakers included Susan Abbott (ANU), Amanda Plowright (SHOUT), Ann Thomson (RSI and Overuse Injury Association) and Jo Stewart, a peer leader for the Living a Healthy Life with Chronic Conditions workshops.

Enablers

Knowledge of the system and their condition were identified as important enablers for consumers. Working with a doctor who is knowledgeable about the condition, treatment options and available supports was also important. Research, particularly using the internet, was mentioned as were self help courses as a way of gaining knowledge.

Some existing services were identified as significant enablers for managing chronic conditions: Job Access, psychology services, hydro pools and other services sere identified as desirable. Good medical services particularly GP services were also identified as enablers.

Participants identified the need for appropriate design for people with chronic conditions.

Participants repeatedly identified support from others, groups, families, friends, as important enablers for management of chronic conditions.

When communication channels are respectful, informed, inclusive and personable they were seen as enabling the management of chronic conditions. Effective communication between health providers facilitated by good record keeping was also identified.

Participants identified good treatment and plans to treat as important in enabling them to manage a chronic condition. This plan could include lifestyle factors. A multi pronged or holistic approach was mentioned.

Having plenty of money was identified as an enabler to self managing a chronic condition.

Participants identified that a positive attitude and determination are useful enablers.

Barriers

Participants were very vocal about the need for health professionals to interact with them as people first. They want respectful, honest, considered and comprehensive communication about their situation.

Lack of Medical Profession Knowledge about chronic conditions was seen as a barrier to the management of those conditions and the variation between doctors knowledge was raised by participants.

Participants recognized that they needed to be well informed about their chronic conditions, however they were struggling to gather reliable information which would help them to successfully manage their chronic conditions. They were also concerned about the level of general knowledge in the community about chronic conditions.

The shortage of doctors in Canberra both GP’s and specialists was seen as a barrier to managing chronic conditions. This was reflected in many comments about waiting times to see doctors.

Participants identified specific areas of service deficit as a barrier to managing chronic conditions. These included, interpreter services, hydro therapy, rehab gyms, well resourced support groups, advice advocacy services, and service closures.

Carers were recognized by participants as central to their ability to self manage their chronic conditions and when carers were not available self management was threatened.

Participants were acutely aware of the need to provide well designed, accessible public spaces and transport and that when this did not exist it was a barrier to managing chronic conditions.

Poor dental services were identified as a barrier to self management of chronic conditions.

Isolation from community was a concern for participants.

Participants repeatedly highlighted the added costs associated with managing a chronic condition: home help, medication, therapy, tests and medical visits. Loss on income was also mentioned. Several participant also mentioned their concerns around transparency in decision making around the cost of ordering tests and intervention.

Participants were frank about their concerns about their experiences where they perceived a power imbalance in their interactions with the medical profession in managing their chronic conditions.

A report is currently being finalised for ACTDGP and will be available on the HCCA website soon.

HCCA Submission to the GP Task Force

HCCA has made a submission to the GP Task Force. It is available online (290 kb Pdf)

Our community needs primary health care that is accessible, clinically and culturally appropriate, timely and affordable. We based our submission on our research and analysis of consumer experiences and expectations of general practice in the ACT.

We would like thank the hundreds of people who took the time to complete the GP Snapshot online survey and share their experiences and expectations of general practice in the ACT. There is a strong level of interest in the community about access to quality health services.

We would also like to thank the many people in our membership and wider networks who shared their experiences and perspectives with us.

A quick summary:

In our consultations we found that consumers’ experiences of primary health care were varied. Some consumers are very well placed with a regular GP who they can see when the need arises. Other consumers reported that the inadequate supply of GPs presents them with significant difficulties in accessing satisfactory care, including for urgent appointments, referrals, scripts or renewals of prescriptions.

Consumers also reported a level of disruption to their health care with the closure of general practices and move to larger corporate medical centres. The impact of closures of practices on consumers is amplified as many existing GP practices have closed their books to new patients.

One of the strategies consumers have developed to deal with the GP shortage is to have a number of general practices they access. A respondent to the GP Snapshot 2009 said that they had “2-3 GPs because we cannot always get to see the same GP due to difficulties getting an appointment” (Respondent 130).

The extension of “corporate” GP practices with a strong profit emphasis is a cause of dissatisfaction for many health consumers in the ACT; reasons given are reduced geographic access, especially if relying on public transport, no doctor of choice and a ‘production line’ consultation process – a particular concern for consumers with chronic and complex conditions.

The majority (81.2%) of respondents have a regular GP. Respondents were asked to provide reasons for not having a GP. The main reasons given for not having a GP were that the consumers can never get into their preferred GP (17.5%) and that GP Clinics are not taking new patients (16.7%).

The GP Snapshot 2009 was designed to capture a snapshot consumer experiences and expectations of general practice in the ACT.

The survey was developed based on discussions with consumer representatives and members of HCCA. Secretariat to the GP Task Force had seen a draft of the survey before publication. The survey was piloted with a group of HCCA members. It included issues such as whether consumers have regular GPs, waiting times, the quality of the interaction and demographic material and included a number of questions that the GP Task Force had asked practicing GPs.

The survey ran from 15 June - 3 July 2009 and was publicised through HCCA members and networks, and media coverage in The Canberra Times, ABC Canberra and 2CC. There were 635 responses. We think that the number of responses demonstrated a strong interest in the community around this issue.

Our preliminary analysis is included throughout the submission to the GP Task Force. A summary of findings is available online (151kb Pdf). HCCA will continue to analyse the results of the survey and post this to the HCCA blog over time.

Workshop: What do consumers need to effectively self-manage chronic conditions?

How patients and health professionals can learn from each other and share information about managing and self managing chronic conditions is one of the key areas of investigation by a collaborative research partnership that has recently been formed in the ACT. This research partnership is between the University of New South Wales, ANU College of Medicine, ACT Health and the ACT Division of General Practice.

While we know that self- management is important for those with chronic conditions, what information and support is needed to make it easier for both patients and health professionals to work together?

Darlene Cox, Executive Director of the Health Care Consumers Association says, “each person has their own unique experience of their condition and illness, which they manage on a daily basis”. But what would make this easier?

What works, what doesn’t work is the topic for conversation that Health Care Consumers' Association and the ACT Division of General Practice would like find out from people in the ACT at a seminar on August 11th. “This is an exciting opportunity for us to meet and hear from people in the ACT and share ideas and experiences of how they manage their chronic conditions”, she said.

To find out more about this seminar or to book a place, contact Health Care Consumers’ Association on ph 6290 1660.

ACT Health Strategy for Chronic Conditions

The ACT Health Chronic Disease Strategy 2008 - 2011 is now available online as a Pdf (322kb).

This document sets the direction for chronic disease prevention, detection and management in the ACT for the next three years.

HCCA supported consumer representatives on the Steering Committee and also made submissions during the consultation phase.

SCIPPS - conference presentation

Dr Jun-Hee Jeon from the Australian Primary Health Care Research Institute, Australian National University sent me the link to the slides from her recent conference presentation based on the interim findings from SCIPPS.

The Experience of Chronic Illness: Balancing Life and Illness

pdf (144 kb) of slides from her presentation

SCIPPS

Serious and Continuing Illness Policy and Practice Study (SCIPPS)

Yesterday HCCA held a forum for a report on the interim findings of SCIPPS. What follows is my summary of the session. I didn't capture all the details but hope this gives you a feeling for the presentation and discussion that followed. The team presented at a conference in June

Professor Nick Glasgow gave an overview of SCIPPS to the participants. He said:

SCIPPS is an NHMRC funded program designed to identify and understand impediments that consumers with chronic conditions have in accessing best practice care, with a view to discern perfect policy solutions to these system impediments to access.

The chronic conditions that have been considered in this study are diabetes, chronic heart failure (CHF) and chronic obstructive pulmonary disease (COPD).

The SCIPPS Research team came to HCCA in November 2006 to outline the research project and returned to present interim findings.

Research Fellow, Dr Yun-Hee Jeon presented the findings of the study to date.

Who was involved in the study?
The research team conducted in depth interviews with study participants.

• 66 participants (52 patients and 14 carers) from ACT and Sydney West Area Health Service
• participants were aged between 45 – 85, living in ACT or WSAHS with the COPD, CHF and Diabetes and most were older than 65
• The participants were referred by acute care wards, community health services and GPs
• significant number from CALD backgrounds
• most identified as experiencing significant financial disadvantage as a result of their chronic condition
• most have more than one chronic condition
• 86% had co-morbidity
• most visited their GP more than once a month

Participants spoke of the difficulty in balancing life and illness. They reported constant juggling of competing priorities of work, family, illness. The limitations to aspects of daily life as a result of their health included: time, physical, financial, and psycho-social. Isolation was mentioned by the majority of participants as an issue.

Key issues
1. Financial hardship
2. Health literacy
3. Health care encounters – experience and perception of standards of care practice
4. Co morbidity conditions

1. Financial hardship

• Affordability of treatment : Medication, oxygen, texts and check ups equipment and support devices medical appointments, Accessing allied health care services and other services
• Affordability of other things: Basic cost of living, Healthy food, exercise, travel, house repair, entertainment
• Pension concession related issues: Eligibility of pension, health care card and concession card
• Health funds and insurance: Access to private health care

2. Health Literacy

• Difference between health care consumers level of knowledge and clinicians perception of their knowledge
• Experiential learning, learning as it takes place, by trial and error but there must be a safer way to share consumer knowledge and to learn form each other

3. Health care encounters

• Difficulty they have with health workers
• Difficult in accessing services
• Manner in which some professionals
• Transport was a major problem
• Waiting for services

Service and system issues identified by consumers and carers:

• access lack of timely services and
• workforce shortage
• fragmentation of services
• lack of continuity of care
• health professional behaviour

Patient related issues identified by health professionals included:
Lack of compliance
poor health literacy

Discussion with HCCA members

Patient Centred Care was discussed. Reference was made to the International Alliance of Patients' Organisations (IAPO) Declaration of patient centred health care.

One participant in yesterday's discussion said:

To make patient centred health care we need to take away the authority of the doctor. It is my disease and it is happening to me.

There was considerable discussion on management plans
ED presentations often mean the management plan has failed.
Who never has to go to ED because their care is well managed: luck, disease progressions lifestyle factors.

• There was agreement that a management plan is an essential tool

Writing these plans is a time to have questions answered, conversations about concerns, write useful things down, prepare advance care plans. This is important to give people a sense of control, ownership and security.

One consumer shared his own experience. He spoke of his Management Plan and Emergency Response Plan. These plans have kept him out of hospital four times in the last 12 months

There is a question of who writes the care plans? How can we reward consumers and staff for contributing to the plan? Financial reward for employees?

Other issues raised were:

• Disturbed employment pattern exacerbated some of the financial issues. Accessing health care when yo are maintaining a job “being sick is a full time business”
• What about identifying consumers with disabilities and see how this impacts in patient experience
• If economic limitations are excluded ( people who can afford access to allied health services) and have higher level of health literacy, do they have a high health status.
• Respite needs to be appropriate for the carer and the person
• Earlier intervention, not end stage of chronic disease but vast majority of chronic conditions would benefit from earlier intervention people who are still trying to manage family responsibilities, work commitments etc
• Need for consumer participation
• raising people’s confidence to take a lead in their own care

I will post the results of the findings once Dr Jeon has sent them on.

I received an email this morning from Laurann Yen, the Research Manager of SCIPPS. Laurann writes:

Thanks so much for organising for us to speak with the group of interested consumers and consumer organisations- it was really helpful to be able to run our findings past the experts, and there were a number of things we picked up which will both suggest a re-think of our interpretation, such as thinking about balancing not as between two competing priorities, but between a range of different issues and alternatives which present themselves and need dealing with; and of course the suggestions for how the system might act differently for a better outcome. I hope we can come back to HCCA again after we have started to try out some interventions and get the thoughts of the group.

Thank you to everyone who participated on the day.

The medical home: another model for managing chronic conditions?

I have been reading around the concept of the “medical home” . This has been a hot topic in the US in terms of disease management. US Physicians from the American Academy of Family Physicians (AAFP), the American Academy of Pediatrics (AAP), the American College of Physicians (ACP) and the American Osteopathic Association (AOA) have offered their support to the medical home model.

I can't say that I am across the whole concept but I am interested in how it is developing in terms of primary care reform.

In short the term medical home describes:

a health care model in which individuals use primary care practices as the basis for accessible, continuous, comprehensive and integrated care. The goal of the medical home is to provide a patient with a broad spectrum of care, both preventive and curative, over a period of time and to coordinate all of the care the patient receives.

Source Deloitte Centre for Health Solutions

The research documents the critical features of the medical home which they have identified as forming the platform for guided self-care management. This can be useful in our discussions in terms of primary care model and managing chronic conditions.,

If you are interested in reading more about this you might like to follow the links below:

The American Academy of Pediatrics (AAP) introduced the medical home concept in 1967, referring to a central location for archiving a child’s medical record. In its 2002 policy statement, AAP expanded the concept to refer to primary care that emphasizes timely access to medical services, enhanced communication between patients and their health care team, coordination and continuity of care, and an intensive focus on quality and safety.

In 2007, a set of seven principles describing the characteristics of a practice-based care model was issued by four physician membership organizations representing over 300,000 physicians. The authoring organizations are: the American Academy of Family Physicians, the American College of Physicians, the American Osteopathic Association, and AAP. The clinicians represented by these organizations provide the majority of primary care in the United States.

Source ICIC

“Disease Management and the Medical Home Model: Competing and Complimentary” — has been published in the peer reviewed journal of Disease Management and Health Outcomes. The author has arranged with the publisher to make copies available through his website.

It seems that there are more challenges to moving to this model that solutions at this stage. There are issues around the start up costs for clinicians and services, including IT infrastructure as well as training for clinicians.