My mission statement

The times we are working in now need a great deal of accelerated change and there must be no negotiating that down. So my mission statement for this part of my consultancy career is to be clear that there needs to be and will be a lot of change from the work that I do with individuals and organisations and if organisations don’t want that, then it is probably best to go somewhere else.

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More thoughts on new models for creating more value from patients.

Filed Under (Health Improvement, Patient involvement, Public Health, Self Management) by Paul on 14-05-2012

I received some interesting comments on last week’s posts about the necessity for investment in improving self-care to improve value for the NHS. Most of my posts concerned the implications of some recent work on diabetes and also articles in the Lancet from last Friday on co-morbidities in Scotland.

On 25 April a report was published in Diabetic Medicine, co-authored by York Health Economic forum, Diabetes UK Joseph Rowntree Development Fund and Sanofi Aventis. One aspect of this report were the frightening statistics showing how much more will be spent on diabetes in 2035 if current trends continue. Whilst I never find disease-specific trends over 23 years convincingly accurate – it is a lot.

More specific was the fact taken from the resources spent on the current service which showed that 79% of NHS spending on diabetes is spent on the cost of caring for complications. This is an enormous amount and graphically makes the point about the expense of a failed long term condition pathway that I made last week.

The vast proportion of the money the NHS spends on diabetes is spent as a result of failures in other parts to stop these complications happening. Without getting too dramatic what we mean by complications in diabetes are truly horrific. They are lifestyle and life threatening.

Of course if a patient needs an amputation as an alternative to death they are grateful for the best amputation service in the world, but what the patient really needs is not the best amputation service in the world, but the best amputation prevention service in the world.

If a CCG were to let a pathway contract for the 1000 sickest people with diabetes in their area, they could incentivise providers to limit the number of complications. If the service could guarantee, by much better home care management of the disease, to cut the number of complications over two years by 20% the sums of money that could be invested in better self and community assisted care would be vast.

But attempts made up and down the country aimed at achieving this have been much more concerned with the sanctity of the organised structures of the NHS than with driving towards the outcomes that very sick patients need and want.

There are now sufficient voices demanding something different.

  • UK Diabetes will work with patients to develop with them a progressive approach to self and community care.
  • Clinical Commissioning Groups recognise that they need to develop an ambitious new commissioning drive that transforms outcomes for these very sick patients.
  • The “Year of Care” approach to care has demonstrated how this works on the ground and how different finances could be constructed and,
  • As I will explain next week there are a number of new approaches to contracting that will help to make that happen.

This has to be the year that we start to really make this happen for both patients and NHS finances.

But this article in the Lancet makes a similar case about patients and self care, but with a very different set of medical outcomes.

For some time now it’s been clear that whilst, as I have argued above, it is essential for health care to organise itself in pathways for conditions and not episodes of care, for those patients with multi and co-morbidities this would not solve the problem.

I was carrying out some work with a hospital that had succeeded in developing its main consultants to begin work on pathways that would have patients receiving integrated care along the various morbidities. The diabetes pathway recognised that most care took place in the home and tried to link the primary and secondary care into that strong pathway. It recognised the importance of self care by including an exercise regime to improve the general fitness of the patient with diabetes. All important stuff.

Similarly the muscular-skeletal consultant was creating a pathway that had an exercise programme – as was the cardiac consultant etc. etc.

But most of the older people in a locality – Scotland in this article – have more than one morbidity. This means that they are moving up and down several pathways at the same time – different nurses, different clinics and of course different exercise programmes.

Luckily patients have some common sense so they won’t carry out all three or four exercise programmes but if they were we would be getting 80 year olds to run through a combined exercise programme that would get most of us ready for the Olympics.

So what we need is not a number of condition specific pathways – although this is much better than episodic care – but a flexible long term condition pathway that will have specific interventions and small and specific branches off of the pathway.

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