BY: DR EDWARD CHAGONDA MBChB (UZ), DIP. VEN. (UZ), DIP. VEN FOOTBALL MEDICINE (FIFA), MMED (Fam. Med) STELLENBOSCH (RSA) Family Medicine Specialist CPCPZ PRESIDENT 2017-2019
No financial association with any Health funders 2
13/9/2017 3
Definition of gatekeeping Quality Health care Ethical implications Advantages of gatekeeping Disadvantages Auditing Conclusion 13/9/2017 4
Patient Doctor/Care Provider Funder Resources Outcomes 13/9/2017 5
Holistic feeling of an individual or group of individuals that they have good health which they would actually have made an effort to achieve Patient Doctor/Care Provider Funder 13/9/2017 6
National policy issue Requirement of a 1 st point of care African context Gatekeepers as sieves Reduces care fragmentation Spain/ UK / USA / Scandinavian countries regulatory Belgium/ Australia/ Switzerland- not stringent 13/9/2017 7
Autonomy Truth telling, effective communication, Informed consent, Confidentiality Non maleficence (Do no harm) Beneficence (Do good) Justice- Fairness Giving to each that which is his due, distributive 13/9/2017 8
Extent to which health services provided to individuals and patient populations improve desired health outcomes 13/9/2017 9
Safe Effective Patient-centered Timely Efficient Equitable 13/9/2017 10
Clear health care path Equity in health Nil/ minimal co-payment Enhanced continuity ER visit decrease (Observation studies) Fewer hospitalisation Shorter length of stay 13/9/2017 11
Lower use of vertical Specialist Care Improves quality health Contains cost- unnecessary interventions reduced Holistic care Addresses co- morbidities Higher patient satisfaction with health care system 13/9/2017 12
Effective co-ordination of conditions Health promotion Preventative health Reduces duplication- waste Complete follow-up enhanced Room for effective co-management 13/9/2017 13
Poorly remunerated Administrators?? Not service providers!! Delayed referral Non-medical negative interference on the care path May lead to needy vertical specialist shortage Avoiding competition for patients Poor utilisation of health services? 13/9/2017 14
Patient satisfaction Health and patient related outcomes Financial sustainability: utilisation and expenditure 13/9/2017 15
Measure United Kingdom United States No of referrals to specialists per 100 consultations with UK general practitioners 8 or US family physicians 9 4.7 5.1 % of referred patients keeping appointments 83 84 * with specialists 8 % of patients with 1 referral to a specialist per year by a general practitioner or primary care physician gatekeeper 10 13.9 31.6 No of specialists per 100 000 population 11 60 125 13/9/2017 Gatekeeping 16 and Wellness Edward
Gate keeping Free access Notes Symptoms, morbidity No difference Quality of life Better Bodily pain and role limitations Satisfaction with care (64% vs. 75%, p < 0.05) 1 RCT Quality of care Better Few studies Utilisation of health care Overall reduction * Length of stay Hospitalisations* Ambulatory care Emergency department visits Expenditures 6-80% 13/9/2017 Gatekeeping 17 and Wellness Edward
Health care ecosystem survives on effective referral system 13/9/2017 18
6 Domains of quality health care. Available online at: https://www.google.co.zw/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=0ahukewih38toznjva hvsdcakhwgjd0gqfggkmaa&url=https%3a%2f%2fwww.ahrq.gov%2fprofessionals%2fquality-patientsafety%2ftalkingquality%2fcreate%2fsixdomains.html&usg=afqjcnf9tdsqcgvpvocizdll9xg76dz8bq. Accessed on 15 August 2017. Balancing rationalities: Gatekeeping in health care. Available online at: https://www.google.co.zw/url?sa=t&rct=j&q=&esrc=s&source=web&cd=12&cad=rja&uact=8&ved=0ahukewj_6lwfy9jv AhVIIMAKHTkxANYQFghsMAs&url=https%3A%2F%2Fwww.ncbi.nlm.nih.gov%2Fpmc%2Farticles%2FPMC1733346%2 F&usg=AFQjCNHJqx4mcmW8KtM4DMzewHTdUL3JUw. Accessed on 15 August 2017. Principles of bio ethics by Beuchamp and Childress. Available online at: https://www.google.co.zw/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=0ahukewihmohx0tjv AhXMK8AKHdWFA6AQFggnMAA&url=http%3A%2F%2Fblogs.biomedcentral.com%2Fbmcseriesblog%2F2012%2F07% 2F13%2Fmeasuring-the-four-principles-of-beauchamp-andchildress%2F&usg=AFQjCNH_4ZFI04A2V4wDAdRvmI45utQ0iw. Accessed on 15 August 2017. Primary care gate keeping and referrals effective filter or failed experiment?-ncbi The Effects of gate keeping: A systematic review of the literature- NCBI-NIH 13/9/2017 19