Managing long term health conditions in the NHS: how our work with COPD is driving quality and cost improvements

May 3, 2011 at 10:13 am 1 comment

By Sophie Byrne

15 million people in the UK have at least one long-term condition (LTC) and they already account for 80% of GP consultation time and 60% of hospital bed days — if you stop and think for a second, these are mind-blowing figures. So it is not surprising to hear Sir John Oldham, the clinical lead for productivity in the NHS, pointing out how healthcare costs are determined by LTCs, such as heart disease, obesity and diabetes. Oldham recognised this presents the NHS with immense challenges, he also emphasised the potential for increasing quality of care and driving down costs by managing LTCs better. His point being, most LTCs can be well-managed through changes to lifestyle, patient education and empowerment. Therefore working with people to manage their condition could help reduce demand on scarce NHS resource.

At Innovation Unit we couldn’t agree more with this analysis. We also think that the best way to do this involves self-management, enabled by education and support tools for patients. This would truly empower users to manage their LTC and make a reality of co-production. But before we get into what we are doing on the ground with GPs and patients to facilitate a shift towards more and better self management, let’s look a little deeper at the problem, and the journey towards a solution.

The NHS and social care professions are working in a really different environment from the one that existed at the beginning of the welfare state. Like other health systems across the world, the most pressing challenge facing the NHS is no longer brief but serious illnesses (such as tuberculosis) but the management of chronic long-term health conditions such as the ones above.

Most of these people are not defined by their LTC and live full and fulfilled lives, occasionally coming into contact with health professionals. However, there are many who suffer acutely because of the severity and poor management of their LTC, leading to frequent emergency and unscheduled care. The challenge for the NHS therefore lies in supporting clinicians and patients’ to better manage these conditions, to achieve quality improvements and financial viability.

In the context of management, McKinsey & Co. have just published a very interesting analysis — “How to design a successful disease-management program” (DMP) — a comparative study of successful and unsuccessful DMPs. Seen through the lens of Oldham’s point, some of their findings are really interesting, and highlight the challenges that lie ahead for how we think about and design our health services. For the past 15 years DMPs, lauded as a panacea for the successful management of LTCs, have not consistently delivered the quality or cost improvements promised. The report describes the five critical factors common to successful DMPs.

These five factors — size, simplicity, patient focus, information transparency and incentives — are summarised in the checklist image above (click image to expand).

Reading about these five factors, I was encouraged by the fact that the “A Year in the Life of: Adding value to COPD services in primary care” project, which Innovation Unit is working on with the North East London, North Central London and Essex (NECLES) HIEC, seems to be pressing the right buttons, and pulling the right levers.

COPD is a long term lung condition that affects approximately 800,000 people in England. The overall cost of care for these patients is just less than 2 billion pounds a year. Much of this care is in emergency hospital admissions, making it the second largest cause of admissions in the UK.

We are, in separate phases of work, working with GPs, GP consortia and 35,000 COPD patients living in Outer North East London to improve both the quality and cost of care for. An outcome of this will be a reduction in the amount of unplanned and emergency admissions.

The project is working with GPs to co-produce tools and interventions, that will deliver high-quality care in line with COPD NICE Guidelines. For example, IT templates for GPs to use in their patient consultations, that will improve data collection, leading to more accurate diagnosis, better conversations and self-management plans. Innovation Unit will be using our facilitation and co-production expertise to help develop these tools.

However, the wider project recognises that radical change will not come just by building the capabilities of GPs — a new relationship with patients is also needed. COPD patients will be involved in co-producing a phase of the work (funded by the Health Foundation’s Shine 2011 program). Patients from 10 GP practices will be engaged to co-produce self-management information. This patient focus – one of the five key factors – will ensure that the project is aligned to COPD patients’ needs.

While the project team are considering all five factors, the most interesting key success factor in relation to our COPD project is information transparency. Successful DMPs systematically collect and analyse both clinical and financial data about the patients they are working with throughout a programme. The data is used internally to continuously develop and improve the programme; and, externally to evaluate the clinical outcomes of a project and the financial savings.

Across an area the size of Outer North East London, this volume of data has traditionally been hard to access and utilise, as different Primary Care Trusts use different IT systems, which don’t necessarily ‘interface’ with anything else, meaning they cannot link up to each other or the internet. So to date it has been really hard to aggregate and compare quality and cost data along a whole care pathway, such as COPD. This is a challenge facing innovators in the NHS more generally. In a time of huge financial pressure and reform it is outcome and cost data that will allow innovators to justify the ‘new’.

By creating a new way of capturing data, A Year in the Life of is working with Health Analytics information systems, which tracks quality and cost data over time at an individual patient level. This means that individual GPs can see how well they are managing their own COPD registers, allowing them for example to target their ‘frequent flyer’ patients with preventative healthcare. For GP Consortia, Health Analytics will allow them to determine how much they are spending on COPD, how different GP clusters are performing and how effective the care they are commissioning really is.

This wealth of information which will be available across Outer North East London is potentially powerful if GPs and other health professionals take ownership of it. Innovation Unit is helping the NECLES HIEC to engage GPs in the co-design of the COPD sections of the Health Analytics system to enable this engagement.

This information transparency will help to ensure another success factor – stakeholder incentives. If a DMP is to succeed, the incentives to comply for all key stakeholders – patients, health providers and commissioners’ must align. COPD patients’ incentives will include non-financial ones, such as improved quality of life. Health Analytics will allow GPs to segment and ‘risk stratify’ their COPD patients and use targeted incentive schemes with different groups of COPD sufferers. Through better management of their COPD registers, the bill for unplanned inpatient care should reduce, meaning individual GP practices have a financial incentive to engage with the COPD project. For GP consortia the project will allow them to commission better, different and lower cost services. We aim to improve patient experience and outcomes over the coming year, at the same time as making smarter use of NHS resources.

This is a potentially prototypical model for GP commissioning, who will be responsible for ensuring that the NHS is responsive to the challenges presented by LTCs. Going back to Oldham’s point about the potential savings in LTCs, enabling GPs to effectively target and support patients with LTCs to better self manage their condition, will enable patients to live better lives and reduce their need for GP consultations and stays in hospital, creating savings for the NHS as a result.

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Entry filed under: commissioning, Health, Public Services.

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