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Wherever possible, patients are supported to identify their own goals and manage their own condition and care.
There needs to be much more emphasis on what the patient values rather than a narrow focus on process measures and biomedical indicators.
Case in point: The Bromley by Bow Centre in London situates itself as a community organization providing general practice and community health service, supporting them beyond their health needs, teaching new skills and activities, and aiming to give them confidence to achieve their own goals.
Primary care is delivered by a multidisciplinary team in which full use is made of all the team members, and the form of the clinical encounter is tailored to the needs of the patient. This will include mental health, home and social care services. Increasingly we expect to see more specialists involved – see the principle on ‘Generalism and Specialism’
Case in point: The Your Health Partnership in the Black Country in the UK has a clinical pharmacist (with prescribing rights) based in its two practices as a core member of the clinical team, supporting medicines management and care of people with complex co-morbidities.
Care is proactive and population health-based where possible, especially in relation to long-term conditions.
Case in point: The ZIO network in the Netherlands delivers evidence-based care for patients with diabetes and with COPD, on a year-of-care basis, working within a contract with health insurers that specifies and incentivize adherence to the evidence-based case management approach.
A theme of these principles is a wish to have the best of both worlds. We need to retain the skilled generalist who can treat the whole patient. But some groups – the very frail elderly, children, and some specialist diseases – may require more specialization within primary care or as part of a wider more specialist network.
Case in point: A central principle behind ParkinsonNet in the Netherlands is bringing in specialist neurologist expertise when necessary, yet having the majority of care delivered at home, through the Internet or in primary care. Vitality Super Partnership in the UK has incorporated specialist medical consultants into their structure.
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