There has been change in the NHS almost from the moment it began. The compromises that had to be made to get it going meant that the structure and management were far from ideal. The endless series of reforms have been attempts to get things right. Some have made improvements, at least until the next one came along. Many have been just different rather than better.
Now that the government is, relatively speaking, pouring money into the NHS to solve the chronic underfunding, even this is not producing the kind of real tangible improvements that will help it win the next election.
It doesn’t take a great deal of imagination to realise that there may be problems that all the reforms have not tackled. One drawback is that the whole operational culture of the NHS and the use of its own peculiar jargon often makes it difficult for those in positions of power to see the real difficulties that patients face. Such initiatives as “patient experience” and “access” mainly deal with how the patient relates to the system as it is, not as it should be.
Further everyone seems to accept results that should be the basis for a revolution, with absolute calm. Take, for example, a finding from the current Evercare disease management pilots for the treatment of the elderly that “better monitoring and education of older patient populations means that at-risk patients can be identified and treated before hospital admission become necessary.”
This means that these vulnerable people, simply by being looked after properly, could be kept out of hospital and have a much-improved quality of life. So what, one might ask, has happened in the past. Why does it take a pilot to realise that their treatment has been deficient?
Now, because other pilots are producing similar results and because there is a wide range of drivers all forcing change into the same direction, there is the start of yet another reform. It will be called the chronic disease management or CDM reform, and there’s no doubt that CDM will become the acronym-of-choice over the rest of 2004.
It has the possibility to make the kind of patient-centred improvements that could save the government’s bacon, providing the results appear quickly enough.
The History
In the late 1980s pharmaceutical companies identified what was know as disease management as the route to enable them to increase the sale of drugs, and they set up dedicated departments to exploit the concept.
Disease management referred to a joined-up treatment of a disease over the whole of its course. So that, as a patient with a chronic condition moved between hospital, for acute treatment, to the GP, for primary care, and the home, for community care, the care was meant to be seamless. The aim was the not the optimisation of any one stage at the expense of others, so that all decisions had to be taken on the basis of the overall benefit to the patient.
Unfortunately two things went wrong. Companies concentrated on selling more product, rather than developing systems to deliver real patient benefits, and the NHS had neither the infrastructure, nor the culture to provide the necessary services.
So the disease management concept went away.
The US Dimension
However, in the USA where are different drivers, it has been widely realised for some time that disease management is an idea whose time has come. A well-accepted definition, due to the Disease Management Association of America (DMAA) is “A system of co-ordinated healthcare interventions and communications for populations with conditions in which patient self-care efforts are significant.”
The Americans have exploited this idea to the full and, apart from the care deliverers themselves, IT companies have developed dedicated programmes to provide the necessary co-ordination and communication. These firms have promoted themselves from being simply IT outsourcers, to the much more elevated role of disease management enablers. Their importance is emphasised by the Boston Consulting Group’s estimate that the markets for IT-based “disease management” services grew from $68 million in 1997 to $500 million in 2000, and could reach $10 billion by 2010.
Such activity must be seen in the context of the situation in the USA, where the chronic diseases of diabetes, cardiovascular disease, respiratory disorders and cancer afflict more than 100 million Americans each year at an annual cost of more than $500 billion in healthcare expenditures and lost productivity.
Back to the UK
After years of refusing to see that US experience was something from which we could benefit, suddenly we had a rash of PCT-based pilots around the country trying out US ideas, and some of the results have been significant. For example, a pilot of active management of conditions at Castlefields Health Centre showed a 15% reduction in admissions for older people and the average length of stay fell by 31%, from 6.2 days to 4.3 days.
This success mirrors that in the US. An evaluation of the Evercare model of case-management for elderly patients found a 50% reduction in unplanned admissions, without detriment to health. There was a significant reduction in medications, with benefits to health and a 97% family and carer satisfaction rate and high physician satisfaction.
Similarly, US provider Kaiser Permanente has, for example, an average length of stay of just four days for patients recovering from hip replacement surgery. This is in part due to their management of chronic disease, facilitated by greater integration between generalist and specialist care.
The realisation that such improvement are possible and the existence of the other drivers shown schematically in the Figure, the UK disease management horizon is about to be transformed.
The putative CDM Public Service Agreement should set out what the government expects to be achieved and provide a very firm incentive to get things done. This will be part of the 2004 Spending Revue and thus effects should be seen in the short-term.
The PSA will be boosted by the forthcoming Long-term Conditions National Service Framework, to be implemented in 2005, and no doubt by both the new five-year NHS Plan, which will take over from its 2000 predecessor, and the Public Health consultation.
Further, the emphasis on shifting care from the secondary to the primary sector will help disease management since it will remove much of the necessity to work across the primary/secondary boundary where communication can be slow, costly and not good for patients.
So is this Nirvana?
By no means. Not even nirvanaesque. But it is on the right road.
Take co-ordination and communication. These imply a joined-up and interconnected service that just doesn’t exist. Further, there are few private companies able to deliver appropriate IT solutions to include coverage of the home-based patient and their carers, and to provide data to all. Although following the pilot schemes there is the start of an appreciation about the level of joint working that is necessary, to get this spread country-wide will require a huge investment of resources with a massive education programme.
Then consider the question of self-care. The Expert Patient programme is a start but there is a long way to go in a service that has a tradition of discouraging the patient from taking too much responsibility.
What will Happen in the NHS?
Particularly the PSA will force the NHS to take disease management of chronic conditions seriously and, because the infrastructure and services are not in place, it will be forced to look to US experience and to buy in know-how, consultancy and both IT and care-based services.
The rumoured scrapping of the public/private Concordat will produce fierce competition amongst the commercial sector, but it could deliver some cost-effective deals for the NHS.
As more services move into the community, the tension between PCTs and the acute sector will increase. That could lead in time to yet another major restructuring process, but this time for very good reasons. The end result would have to be a more joined-up service, but that is another story.
What is in it for Industry and the Private Care Sector?
The scope is well beyond what would have seen possible when the Concordat was set up by Alan Milburn, but in a much more aggressively commercial atmosphere.
The NHS has the task of transforming itself very quickly into the biggest disease management organisation in the world. If the Department of Health is plugged into the vision outlined above then the £15 billion figure reported by Clinica as the cost of programmes to buy in medico-technical services, begins to intellectually hang together.
PCTs will have to buy services focused on integration and communication, and will have to provide their patients with self-care education, service and back-ups. Many appropriate self-care products do not exist. Thus there is great scope to do business.
The pharmaceutical companies have the resources and the knowledge to play a major role in product and care provision, and they should find it easy to import US know-how. Pfizer seems to have stolen a march in Haringey, but providing the rest get their act together quickly, there should be enough for all.
Since success can’t come too soon for the government, they will be very supportive of initiatives and the added commercial attraction is that the opportunity is now. If the whole vision comes together we shall all benefit.
The Local Delivery Plans of PCTs have many references to Chronic Disease Management. A typical example:
Modernising Health and Care Services – Sunderland PCT Local Delivery Plan 2003/2006
We have set up a new Modernisation and Reform Group to look at services for those with chronic illness. This year we will be focusing on the following services:
· Diabetes - implementing the priorities and standards set out in the National Service Framework.
· Chronic Pain - to review the chronic pain service at City Hospitals Sunderland and ensure its continuity.
· Respiratory Disease - developing support services to improve community care and avoid the necessity for admissions to hospital.
· Brain Injury - we will be considering the development of a local integrated service for people with traumatic brain injury.
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