Published: 12/08/2004, Volume II4, No. 5918 Page 16 17
Greater emphasis on chronic-disease management is welcome, but focusing too much on US models may mean overlooking valuable lessons from the UK, including those on diabetes
At last, chronic disease is being taken seriously. The Department of Health recently heralded chronic-disease management as a 'significant and exciting challenge for the NHS'.
Previously left on the margins of NHS policy, it is now in the spotlight, with implications across primary and secondary care.
People with chronic conditions consume a high proportion of NHS resources. Collectively, people with diabetes alone spend 1.1 million days in hospital each year. Chronic disease is also increasing - current estimates suggest that by 2030, chronic disease in the over-65s will have more than doubled.
Much emphasis has been put on cutting waiting times and improving acute care, but by getting services right for the millions of people with chronic conditions, there is a huge opportunity to give many more people what they want from the health service.
Furthermore, diabetes provides an exemplar for quality CDM and the wider emphasis on longterm conditions. Indeed, the second Wanless report, Securing Good Health for the Whole Population, highlighted the need for the government to tackle prevention of diabetes and its complications with a more co-ordinated and long-term approach.
Chronic-disease management has now been included within the public service agreements between the Treasury and the DoH. The relevant PSA requires the NHS to 'improve health outcomes for people with longterm conditions by offering a personalised care plan for vulnerable people most at risk; and to reduce emergency bed days by 5 per cent by 2008, through improved care in primary care and community settings for people with longterm conditions'.
The recently published NHS improvement plan also draws attention to the health and cost benefits of effective chronicdisease management.
It prioritises the need for better information about and for patients, as well as improved support and care for people with chronic conditions, provided closer to their home.
Work on chronic-disease management has already begun in some areas. Pilot sites are to be established in each strategic health authority, where patients with more than one chronic condition will be intensively case managed to reduce inpatient admission.
However, there are dangers in over-emphasis on chronic conditions as a generic group.
There are common building blocks throughout chronicdisease management: the need for early diagnosis and treatment; a named contact; a personalised care plan and structured education. But when you start scratching below the surface, differences begin to emerge. For example, education to help someone manage diabetes will look very different from education about asthma.We need to recognise the limits to a generalised approach.
There is also a lot of work to study based on US models.
Evercare has delivered impressive results in the US. It showed a 50 per cent reduction in unplanned admissions, without detriment to health. It also allowed a significant reduction in medication, with benefits to health, and saw high satisfaction rates, both from the family/carer and from the healthcare professionals involved.
We have seen similarly dramatic results from another US organisation, Kaiser Permanente.
Both these approaches are being piloted in the UK. But have we really looked closer to home yet?
Certainly in diabetes we know what good care should look like. It is clearly described in the national service framework for diabetes in England and its equivalents in Scotland and Wales.
All the UK diabetes frameworks highlight the principle of integrating service delivery to provide systematic care, including a focus on prevention and self-management. Following this approach throughout a whole health system provides the framework for improving chronic-disease management and health outcomes. The key is a greater proportion of patients being treated and managed in the community by competent practitioners, rather than accessing acute care.
Statistics show that on average, a person with diabetes spends around three hours a year with a healthcare professional. This means the individual is managing his/her own condition for the other 8,757 hours of the year.
Regardless of how poorly someone appears to be doing it, they are self managing. The challenge is to provide care and support to allow them to do it well.
The management of a condition by the patient requires the delivery of personalised systematic support. But what does the term systematic care really mean? It is about providing regular reviews, based on accurate registers and care plans. It is the means for ensuring delivery of advice, information, education, investigations, support and treatment. A co-ordinated and clear system of care must be established locally through primary and secondary care.
At the heart of this system lies a clear, individualised care plan to support the involvement of individuals in their own care.
This process should include agreeing personal goals and how an individual's condition is to be managed until their next review.
Furthermore, it should identify their health, social care and education needs and decide how these will be met and who will be responsible for delivering each service. A named contact to help navigate the system should also be considered.
Structured education is crucial.
Individuals must be given the skills and confidence to take control of their condition. This requires high-quality, structured and continuous education.
Education programmes should be locally organised and developed in consultation with the people who have the condition.
Individual needs, including age, culture and language should always be taken into account.
The expert patient and other peer support programmes provide additional opportunities to learn how to live with a chronic condition, but are not a substitute for structured education.
It sounds obvious but chronic disease cannot be managed without a clear understanding of who in your area has a chronic condition and where they receive their care.
The identification of people at high risk and those already diagnosed is the precursor to providing recall, systematic care, support and review. Accurate registers at all levels of the NHS provide the means to achieve this.
Regularly audited registers should ensure that those who have trouble managing their condition - and are therefore at high risk of complications - are easily identified. Registers should also highlight newly diagnosed patients who may be struggling to adjust to their condition.
As we look forward we can see a future of growing patient choice and services based on the needs of the individual, not the individual fitting in with the needs of the service.
To make choice a reality, people need to be aware of what they have a right to expect.We also have to shift the culture of the system, so that individual needs are respected and responded to.
But choice is not everything.
People with long-term conditions also need well planned, joined-up services delivered by qualified professionals.
Making sure of this will take integrated local planning by all those involved and, particularly, genuine involvement of the people the services are being designed for.
Benet Middleton is acting chief executive of Diabetes UK.