Published: 02/12/2004, Volume II4, No. 5934 Page 20 21

Is the NHS focusing too much on replicating overseas models of care, or is it a wor thwhile pursuit of best practice? Benet Middleton and Barbara Hakin draw the battle lines

FOR BENET MIDDLETON

Benet Middleton is acting chief executive of Diabetes UK, which he joined in April 1999 as director of policy and communications. Before joining Diabetes UK, he was head of policy for the Consumers' Association.

AGAINST DR BARBARA HAKIN

Dr Barbara Hakin is chief executive of Bradford South and West primary care trust. She was a GP in Bradford for 20 years and latterly a primary care group chair. Until January this year she led the Modernisation Agency's National Primary and Care Trust Development Programme.

Benet Middleton: The recent focus on US models of care in relation to the management of longterm conditions reminds me of the joke about the drunk looking for his key. He is searching under the pool of light coming from a lamppost. He actually lost his keys elsewhere, but he says there is no point looking there as it is too dark to see anything.

There may well be lessons to be learned from abroad, but while we are still struggling to learn from what is already working well here there is little to be gained from looking elsewhere.

When Diabetes UK campaigned for a national service framework for diabetes, we did this from frustration. People with diabetes were telling us about the massively mixed bag of care they were getting.

While some were receiving top-class support, others were being very badly served.

There was no problem about describing in the NSF what good care should look like - there was widespread agreement. The challenge was how to get it implemented across a diverse health system.

In the devolved NHS, centrally set targets are meant to be melting away. But there is still a need to set benchmarks and identify best practice - and that means transferring learning. Why should we be any better at doing this in the new environment, and why should we complicate matters further by putting too much emphasis on learning from US insurance-based models rather than our own success.

The value of learning from the UK as opposed to the US has recently been underlined by the work of National Primary Care Development Team. It showed the potential for achieving greatly improved outcomes through transferring what was working well in diabetes care provided in some areas to those places with poorer performance. We would all like to see that approach replicated in other fields.

My other concern about the current approach relates to the overemphasis it places on case management.

One of the main lessons being drawn from the Evercare pilots in the UK is the importance of managing the highest-risk older patients in order to keep them out of hospital. This needs to be done to help them improve their quality of life, but the longer-term sustainable benefits are to be had from focusing on broader groups of existing or potential patients.

Prevention, early diagnosis, good patient education and early support is the best way to prevent the progression of long-term conditions and therefore reduce the number of high-risk patients, with attendant high admission rates.

I conclude that the energy and resources expended on looking at US models might be better invested in sharing the good practice that already exists at home.

Barbara Hakin: The NHS has made enormous improvements in recent years, modernising the delivery of care and finding a range of innovative ways to offer patients earlier access, convenience of location, and treatment earlier in the course of the disease.

As Benet points out, many of these innovations are home-grown, with ideas generated by one hospital or primary healthcare team, then spread using the successful tools and techniques from teams like the NPDT and the Modernisation Agency.

But we should not assume that all the answers can be found in this country - or even in healthcare. The way services are delivered abroad - not only in the US - has already had a powerful impact on the NHS.

We have learned lessons from Kaiser Permanente on how strong clinical engagement can deliver benefits for patients. The Evercare programme pays meticulous attention to care for frail elderly patients in a way that has been mirrored in many parts of the NHS.

Why did it take me so long to realise that an intensive package of support for patients with the most serious conditions would not only benefit patients, but would also save resources? This approach is needed for services that prevent disease or reduce complications, as Benet points out.

Perhaps he is surprised at the speed with which the NHS has embraced the Evercare model.

Certainly, it seems that the approach developed at the Runcorn practice of national clinical director for primary care Dr David Colin-Thomé is very similar and could perhaps have been spread long before the import of Evercare. So why the difference?

I am prepared to concede that the NHS can be guilty of the 'not invented here' syndrome, which suggests we might all be more prepared to accept an idea which has its origins across the Atlantic. But this does not shake my belief that we should look aboard for inspiration.

In addition, we should not underestimate the lessons we can learn from other industries.

Understanding techniques used in advertising may help us to decide how to persuade patients to change to a healthier lifestyle. Those with expertise in retail have much they could teach us about commissioning, procurement and quality control.

So I believe there is a clear need for 'both/and'. We must constantly seek out new ways to deliver care that are both more effective and efficient - and we must look everywhere we can.

Benet Middleton: Barbara, I couldn't agree more with your underlying argument: while we are getting better at improving services, we need to lose a tendency to reject ideas from elsewhere and look to the lessons to be learned - whatever the source.

A key element of managing longterm conditions is recognising that it is the patient doing the managing.

The challenge to the health service is adapting to engage with patients' lives in order to support them, not the other way around. This means learning from patients.

I think the importance of people over systems is beginning to become more widely understood.

Certainly, patient involvement featured as one of the lessons to be learned from the NPDT work on diabetes recently and is central to the diabetes NSF.

However, there is a real danger that - due to the public service agreement targets of a 5 per cent reduction in emergency bed days by 2008 and the concentration on 'those most at risk' - all we will learn from the US models is how to develop top-down models of managing long-term conditions.

I am concerned that will not give us sustainable improvements in outcomes for conditions like diabetes where we need to help people avoid becoming part of the high-risk group in the first place.I might be prepared to put aside my concerns about comparing NHS management of long-term conditions to US models of care in order to gauge their success, but only if we can establish a collaborative approach in which patients help design services and shape the sort of care they receive.

Barbara Hakin: Our patients have a broad range of problems and needs and, as such, one size does not fit all.

Of course Benet is right when he says that we need to provide health improvement services for those who are not yet diagnosed or have not yet developed disease.

For patients with a single disorder, the evidence is that a rigorous approach to controlling their disease by the NHS will improve mortality and morbidity. A focus on self-care will hugely benefit their quality of life, too.

But what we see from the US experience is that those with complex diseases and who have become frail as a result need a different package of support to help them feel as well as possible and retain maximum independence.

This is not just about meeting targets: it is what both the public and our patients want. They want us to provide services that are sooner, nearer and earlier in the course of the disease. We also need to provide the most intensive care in the least intensive setting.

All these initiatives help us to meet their expectations and we must manage to spin all the plates and deliver the whole spectrum.

Searching out the best ideas from near and far will help us achieve this goal. That, too, is what the public both expect and want.

In next week's HSJ, Ann Dix reports on Dr Colin-Thomé's unique care programme and its potential as an alternative to Evercare.

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