Neil Churchill: NHS savings on long term conditions

Recently I bought a television with no instruction manual. I had to book an engineer every time I had a question. As there was only time to ask about one function at a time, I quickly became a regular client. My efforts to learn on the job and experiment with a soundbar, however, resulted in my plugging in the wrong cable and blowing the wiring, requiring a visit to the repair shop.

Let’s start with spotting and managing risk. This should drive care planning

Couldn’t make it up? OK, I admit my electrical retailer did not behave like this. But it is how I and many others experience the management of our long term conditions.

The culture of dependency we have created for patients with these conditions was brought home to me when I had a persistent problem with a routine repeat prescription for my asthma inhaler and my GP kept signing off the wrong drug. It took three highly qualified health professionals to fix it. Not to mention a lot of my time.

None of this would have been necessary if I had had an agreed care plan. Instead, the way we organise care means patients can be dependent on doctors every step of a care pathway.

Encouraging patients to be more self sufficient could go quite a way towards realising the required savings of £2.7bn a year by 2014 from the NHS’s long term conditions budget, freeing health professionals up to focus on those at risk and improving the patients’ experience. This is behind the approach being taken in the new COPD strategy, which now includes asthma, too.

Here is a four point plan:

• Let’s start with spotting and managing risk. This should drive care planning. People who have already been hospitalised for their long term condition are much more likely to be at future risk. Yet many people say they were discharged without being told how to avoid a repeat. Patient-reporting outcome measures like “DoloTests” can also be used in primary care to identify patients whose health is deteriorating, to ensure targeted interventions.
• Next step, education. It seems self evident that education is needed when people are first diagnosed with a long term condition. But a differentiated approach is often needed. People from the commuter belt like me will often just need an information prescription and signposting to a website for more help. In disadvantaged areas, face to face support is often required. NHS Kirklees has used lay health trainers to engage patients and influence their behaviour, for example encouraging people to exercise or take their medicines.
• Third, there is huge potential to use simple technology. Pharmacists can spot from prescribing data the warning signs when things are going wrong for a patient, which should spark appropriate action. Telemedicine can offer commuters annual reviews online rather than requiring a morning off work. Reviews are already based on templates and can be incorporated into disease management tools that allow patients to monitor symptoms. Even better if care plans go online, too.
• Finally, targeted interventions. It is often remarked that everything the health service needs to do to improve and reduce hospital admission is already being implemented on a small scale somewhere in the system. Chief among these are targeted telecare services run alongside community matrons and rapid response alternatives to accident and emergency for people needing help out of hours. The task here is often to pull together what works on a significant practice scale.

NHS South East Coast is supporting a personalised care planning project through its Regional Innovation Fund this year, which will test a new operational model in one GP practice before rolling it out to practice-based commissioning clusters. The national QIPP programme for long term conditions has targeted a 15 to 20 per cent reduction in unscheduled hospital admissions by April 2011. Measures like these should make a 20 per cent reduction the bottom end of our expectations.

But if self sufficiency is one cornerstone, another must be altruism. Talking to older patients, I often feel that we have lost our sense of responsibility towards other users of limited healthcare resources. Patient responsibility is at the heart of the NHS constitution, alongside patient rights.

The banking crisis and the imminent retrenchment of public services have surely created an opportunity to reinvigorate that sense of responsibility. Perhaps our annual review should include the footprint we leave on the NHS, through the drugs we use and appointments we miss.