Everyday diseases and everyday solutions

pharmafile | July 8, 2004 | Feature | |   

What is all the fuss about chronic disease management? Go to virtually any NHS conference these days and you will hear that the major challenge of the future is chronic disease management (CDM), yet few define its terms and how the various aspects can be pulled together. Who will be involved and where does Kaiser Permanente and Evercare fit into it all? Why is it such a challenge and what can the pharmaceutical industry do to help? These questions will hopefully be answered in this article.

What is chronic disease?

The definition of CDM can be a problem and the term is rarely defined in a satisfactory way. For some we are talking about simply a disease that 'lasts a long time' while others look for more complex definitions – a disease which has one or more of the following characteristics:

• Permanent, leaves residual disability
• Caused by non-reversible pathological alternation
• Requires special training of the patient for rehabilitation, or may be expected to require a long period of supervision, observation, or care

These definitions help, but the real issue here is to focus on why chronic disease matters to the NHS. The essence is that CDM covers those patients (and carers) who are engaged in a long-term and continuous relationship with the NHS over an illness or disability that is not self-limiting, isn't going to go away, and requires ongoing care. Examples of conditions include:

• Diabetes
• Asthma
• COPD
• Hypertension
• Epilepsy
• Multiple sclerosis

The Long-term Medical Conditions Alliance (LMCA) currently list on its website over one hundred member organisations dealing with various conditions (www.lmca.org.uk). Put simply, a lot, and everything that isn't acute care!

In the UK as many as 17.5 million adults may be living with a long-term health condition – in the past 50 years chronic diseases have become the number one cause of both morbidity and mortality, and account for three quarters of all healthcare expenditures, according to research done by The Institute for Health and Aging University of California in San Francisco in 1996.

Before then, according to Dr Kate Lorig and Halsted Holman, MD Stanford University School of Medicine Stanford Patient Education Research Center, acute illnesses were the major problem and neither of our major healthcare systems has adapted well to working with these chronic conditions.

Why all the sudden interest?

It is important to recognise the real issue of death and disability but also recognise cost issues – the problems are widespread and international and few healthcare systems cope well with chronic disease.

We also know that people are living longer in the UK and that older people are more likely to have a long-term health problem. Changes in the size and age structure of the population are significant and their impact substantial.

Over the next twenty years, the population is projected to increase by around five million people. The number of and proportion of elderly people will rise as the baby boom generations reach older age and mortality rates continue to fall. According to an independent 2002 review (Securing Our Future Health: Taking a Long-Term View) by Derek Wanless, the number of the very elderly is expected to increase by more than a third, during that period.

There is, of course, debate as to whether the increase in expenditure on caring for older people is because of age or simply increases the closer we get to death, but this argument will be left to those more equipped to deal with it. The message is that CDM is going to be a major challenge to the NHS in common with other healthcare systems across the world. But what are we doing about it in the NHS?

Interest in 'Kaiser-type' models

There has recently been an explosion in interest in looking at US-based systems, particularly those operated by Kaiser Permanente, a working partnership of two organisations: the non-profit Kaiser Foundation Health Plan and Hospitals and the Permanente Medical Groups, a health management organisation with over nine million members and Evercare/United Healthcare, an organisation serving some 500,000 clients across the US.

The whole movement to examine these issues was sparked by the article Getting more for their dollar: comparison of the NHS with California Kaiser Permanente that appeared in the BMJ in 2002. The major thrust of this article was to argue that a different system of care could improve outcomes whilst decreasing cost. It analysed the Kaiser model which is summarised below.

Kaiser Permanente population-based management of chronic conditions involves segmenting the population into distinctive sub-populations with different care needs and objectives. Specific interventions can then be implemented to maximise health and satisfaction and, if possible, reduce costs.

Some interventions may actually increase or shift costs, but they result in significant increases in quality or satisfaction. To be successful, population-based management must first identify all patients with a chronic condition and monitor the status of that population over time on both outcome and process measures.

Outreach to patients who fail to meet specific parameters is critical. The search is on – if  population-based care management was the key to PCT problems in the NHS how could this be exploited?

There followed a rash of visits to the US, from policy makers to clinicians, and reviews by many eminent bodies such as the King's Fund January 2004 report: Managing Chronic Disease: What can we learn from the US experience? Managed care organisations were studied and comparisons drawn with the UK.

Perhaps the key conclusion is drawn by the Fund which says: "Better primary care and better integration between primary and secondary care can play a significant part in reducing the use of expensive and disruptive hospital stays for people with chronic conditions.

"But in England there are large variations in hospitalisation rates associated with chronic diseases between different primary care trusts (PCTs) that serve similar populations. These suggest the need for a wider, more systematic approach – and accompanying incentives – to help primary care providers manage chronic disease in consistent and targeted ways."

Under the auspices of the National Primary and Care Trust Development Programme two projects – Evercare/United Healthcare and Kaiser Permanente -have been established to carry this forward (for more information see the website at: www.natpact.nhs.uk).

Evercare/United Healthcare

This project involves nine PCTs working with United Healthcare to implement the Evercare model of proactive care for the most vulnerable. In America this model has been successful in keeping older people healthy and out of hospital by investing in services provided in the community.

An enhanced nursing role is at the heart of the Evercare model and these nurses work closely with GPs, hospital doctors and other care staff as part of a primary care team to deliver integrated care.

Kaiser Permanente

Nine PCTs are working to apply the experience of the Kaiser Permanente organisation in their local health system. Older people and those with long-term chronic disease suffer particularly where services are fragmented. International evidence shows that better integration between primary, secondary and social care can reduce hospitalisation and yet provide better care. Services need to be redesigned around patients and focused on prevention, assessment and self-management. They also need to be integrated and co-ordinated.

Several PCTs are exploring different approaches to managing patients with chronic conditions by redesigning integrated services, modelled around patients with complex needs. The aim is to provide alternatives to hospitalisation by building capacity and developing services in primary and community settings. Meeting the needs of patients with complex chronic conditions in these settings can help manage demand for secondary care services, reduce avoidable admissions, shorten lengths of stay, and free capacity in acute settings. The six key principles of the Kaiser Permanente model are:

• Integration
• Active management of patients
• Doctors are leaders
• Keeping patients out of hospital
• Self care and shared care
• Use information

Managing chronic disease UK health policy

This recent interest in the US experience doesn't stand alone. It has to be seen in the context of other initiatives in CDM. Whilst space doesn't permit a detailed examination, some reference to three key areas may help.

National Service Frameworks (NSFs) are a central strand of government policy in attempting to improve health and reduce inequalities – they set national standards, define service models, and establish strategies to support implementation and performance measures to monitor progress.

Former health secretary Alan Milburn announced the NSF for Long Term Conditions in February 2001 saying:  "A particular focus will be on the needs of people with neurological conditions and brain and spinal injury. It will include services for people with epilepsy, multiple sclerosis, Parkinson's disease, motor neurone disease and other similar conditions.This NSF remains 'in progress' and is seen by many as a key strand in government policy, informed by the US models described above, but also involving a heavy round of consultation with patient and representative groups.

New models of contracting for general medical services

PCTs are under a duty to secure the provision of primary medical services, to the extent that they consider it necessary to meet all reasonable requirements of their populations. PCTs have four different routes for discharging that duty: General Medical Services (GMS), Personal Medical Services (PMS), Primary Care Trust Medical Services (PCTMS) and Alternative Personal Medical Services (APMS).

PCTs can enter APMS contracts with any provider that meets the provider conditions set out in directions. This includes the independent sector, voluntary sector, not-for-profit organisations, NHS Trusts, other PCTs, Foundation Trusts, or even GMS and PMS practices.

PCTs will also be able to provide services themselves by directly employing staff, under the PCTMS route. The PCT may wish to employ full-time staff to provide a full range of services, or employ staff on a sessional or part-time basis.

Each of these arrangements will have some form of quality and outcomes incentive similar to that involved with the new GMS contract – the Quality and Outcomes framework (QuOF).

The pharma industry will readily recognise this as an opportunity to help practices maximise income, but how many see it in the context of improving the management of chronic disease? That is its real intent. Have a look again at the content and you will see how much of the QuOF is actually about incentivising general practice in this area and the new pharmacy contract won be far behind.

Expert Patient programme to make impact

The Expert Patients Programme (EPP) is an NHS-based training programme that provides opportunities to people with long-term chronic conditions to develop new skills to manage their condition better on a day-to-day basis.

Set up in April 2002, it is based on research from the US and UK over the last two decades which shows that people living with chronic illnesses are often in the best position to manage their condition. Provided with the necessary 'self-management' skills, the evidence is that they can make a tangible impact on their disease and quality of life.

CDM is critical to the NHS, will impact on prescribing, and presents a huge opportunity for the industry in partnership arrangements, as long as it gets on board.