Rising to the challenge: will the NHS support people with long term co
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《英国医生杂志》
1 Mill Stream Surgery, Wallingford OX10 6RL, 2 Department of Health, London SW1A 2NL, 3 Health Service Management Centre, University of Birmingham, Birmingham
Correspondence to: T Wilson tim.wilson@gp-k84036.nhs.uk
The NHS is waking to the challenge of chronic diseases. Three researchers who have worked in the Department of Health discuss how the NHS might rise to the challenge of better supporting people with long term conditions
Analysis of the British household panel survey (2001), the health survey for England (2001), and general household survey (2002) has given us a great insight into how long term conditions affect people in England.3-5 The data show that:
Around 6 in 10 adults in the household population report some form of chronic health problem;
People with chronic health problems are significantly more likely to see their general practitioner (they account for about 80% of consultations), more likely to be admitted as an inpatient (on average about twice as likely given a particular problem, but up to seven times more likely for cancer), and use more inpatient days than those without (fig 2);
Health care utilisation intensifies with the number of problems reported (the 15% of people with three or more problems account for almost 30% of inpatient days);
Some people are highly intensive users of inpatient services: 10% of inpatients account for 55% of inpatient days, and within this are the very high intensive users, with 5% of inpatients accounting for 42% of inpatient days (fig 3);
People with any long term problem are about twice as likely to be intensive users than those without. Intensive users on average have three chronic problems, and are likely to be found among older people.
Fig 2 Likelihood of respondents to British household panel survey 2001 (n=5500) with chronic problems needing to use health services
Fig 3 Cumulative days in hospital spent by patients admitted as inpatients. Source: analysis of British household panel survey 2001
From this we can deduce three clear messages. Firstly, as does the rest of the world, the United Kingdom has many people with chronic disease—and we need an NHS that supports them. Secondly, people with chronic disease are disproportionate users of the health system. Thirdly, a group of patients, who tend to be older, have multiple long term problems and are spending disproportionate periods in hospital.
The commonest reported problems are those of the musculoskeletal and cardiovascular systems (table 1). Chronic diseases, although often associated with older adults, also affect children. In the United Kingdom, 15% of the under 5s and 20% of the 5-15 age group are reported to have a long term condition. The likelihood of a long term problem increases according to socioeconomic circumstances (fig 4).
Table 1 Prevalence of chronic problems in the British household panel survey, 2001
Fig 4 Percentage of respondents to general household survey 2002 (n=13 000) with a longstanding problem
NHS reform and the challenge of long term conditions
Some features of the NHS sustain support for people with long term conditions. These include well established primary care teams (including community nurses and general practices) and a network of other community providers, including pharmacists and therapists. Crucially, having patients registered with a general practice offers great opportunities for supporting those with long term conditions and also provides patients with an unparalleled certainty about who will coordinate services and act as the final repository of care. For those with more than one condition, this is fundamental.10 However, the variations in care for people with chronic diseases by general practice are currently unsupportable,11 and changes in policy are seeking to reduce these variations.
The NHS is moving towards a system that is highly dependent on the effective commissioning of services by primary care trusts; in effect they are charged with ensuring that patients receive the support they need. As primary care trusts build their skills to more effectively commission care, they can ensure that financial incentives and mechanisms result in delivery of the best care for patients with long term conditions. To support trusts in their commissioning role are a series of financial incentives. Perhaps most significant is the new general practitioner contract, which includes the quality and outcomes framework, a reward system for the management of 10 important chronic diseases. Using an automated payment system based on the electronic patient record, this provides strong incentives for better clinical management of these conditions.
Another financial incentive is payment by results. This fee for service payment mechanism could affect patients with long term conditions in four ways:
Providers of specialist services are more likely to respond quickly to the needs of patients with long term conditions who need episodic care (such as an outpatient visit, cataract surgery, or joint replacement)
Money previously locked in hospital systems can be released for the benefit of community based services; research on the benefits of investing in ambulatory sensitive conditions (like heart failure or chronic obstructive pulmonary disease) indicates that this results in considerable benefit12
Acute trusts will make savings by reducing the length of stay, especially for those patients who occupy beds the longest, who are generally people with long term conditions
It might also have a perverse incentive: encouraging hospitals to increase (or maintain) activity inappropriately or face financial deficits.
The twin issues of reduced length of stay, and the incentive of hospitals to increase activity for patients with long term conditions, means that primary care trusts will have to work hard to balance investment between community based health and social care services, who pick up early discharges, and hospital departments, who see activities decreasing. The trusts can of course engage clinicians in the commissioning process to ensure that patients with long term conditions get the most appropriate care, most notably by giving practices an indicative budget. Another mechanism is to encourage networks of generalists and specialists to become involved in the commissioning process for particular disease areas.13 We are learning more about the importance of involving patients in the commissioning process; patients as co-designers of the healthcare system are potent allies for primary care trusts.
The trusts' ability to commission care effectively, including care for people with long term conditions, continues to be debated. Primary care trusts were established in 2002 and are still relatively immature organisations. Many have yet to make the most of their control of around 80% of the NHS budget. The balance of power within the NHS has resided with the providers of acute services, and the independence of these providers is being reinforced by the creation of NHS foundation trusts, a new kind of organisation managed at arm's length from the NHS. Primary care trusts in many parts of the NHS have found it difficult to negotiate on equal terms with acute services providers, in part because they lack the expertise and information to challenge the people running hospital services. Collaborative commissioning, in which neighbouring primary care trusts agree to work together to negotiate with providers, is being used in some places to address this issue. In parallel, the government is encouraging the trusts to devolve their budgets to general practices so that practices can commission some services directly. These developments have created uncertainty about the future of the commissioning function in the NHS.
Design of the delivery system
The development and use of guidelines will be facilitated in due course by the large investment in the National Programme for IT (information technology). A patient record, accessible across every part of the NHS, will go a long way towards overcoming some of the potential divisions in a pluralistic delivery system. Many other aspects of better support for long term conditions will also be facilitated by the programme: better planning for populations of patients, identifications of their needs, and support for commissioning, including easier monitoring of contracts. These will not be universal for some time, and the implementation will be difficult if the experiences of other healthcare IT programmes are repeated.19
Decision support
The evidence base backing the use of generic programmes to support patients, like the expert patient programme and disease specific self management programmes for conditions like diabetes or chronic obstructive pulmonary disease, is strong.21 Although the expert patient programme is showing mixed results, it is clearly having a major impact on many patients.22 The challenge for the NHS is how to move from a programme that has trained 12 000 patients to one that can support the many millions of patients who might benefit. This poses three questions. Firstly, does the capacity exist to deliver the expert patient programme or disease specific self management programmes on this industrial scale? Secondly, with its limited resources, the expert patient programme has spare capacity (personal communication, Harry Cayton, National Director for Patients and the Public at the Department of Health, England); what will make the "prescription" of self care as routine as the prescription of a statin in heart disease? Further, will routine self care for all be as effective as it is now, in groups who have volunteered? Thirdly, little is known about the sustained effect of these programmes on life long conditions; what reinforcement is necessary?
Community resources and policies
Major reforms in the English NHS—including a massive investment in the NHS as a whole, the potential of effective commissioning, and opportunities opened up by the National Programme for IT—offer obvious benefits to patient with long term conditions. Challenges remain: ensuring commissioning is indeed effective, using incentives such as payment by results, avoiding the risks of NHS foundation trusts pursuing their own interests at the expense of the wider system, and achieving closer integration of service provision. These reforms could benefit patients who have long term conditions, but they carry tensions that could create problems if not properly applied or regulated (table 2).
Table 2 Effects of system changes in the NHS on people with long term conditions
Case management is a target for the Department of Health. If the full potential of the current policy emphasis on chronic diseases is to be obtained, the NHS will need to link case management to more consistent disease management and self management in what amounts to nothing less than a paradigm shift in the way in which services are provided. At the heart of this shift is the need to move away from the acute care model, in which health services rescue patients when they become ill in an episodic manner, to a chronic care model, in which the resources of the healthcare system and communities are harnessed to provide high quality care over time.
Summary points
As the number of people with long term conditions in the United Kingdom rises, the NHS needs to adapt so it can respond to their needs
The NHS is experiencing investment and reform
Programmes already in place (especially case management by community matrons) are supporting people with long term conditions
Many reforms will create tensions in the NHS that, if managed well, will reap benefits for patients with long term conditions
The NHS must carefully monitor progress on supporting people with long term conditions so that it can learn, adapt, and make best use of the available opportunities
TW has been a senior policy analyst in the Department of Health strategy unit and CH has been its director. This article represents the opinions of the authors alone and does not constitute official Department of Health policy.
Contributors: TW did much of the literature search and some analysis, brought together the evidence, and was the lead author of this article; DB did the most of the data analysis and epidemiological work; CH organised and planned the work on long term conditions in the Department of Health and helped write this article.
Competing interests: DB is employed by the Department of Health. CH and TW are occasionally paid to speak and advise on policy matters, including the support of long term conditions.
References
Smith R. Is the NHS getting better or worse? BMJ 2003;327: 1239-41.
Secretary of State for Health. The NHS improvement plan 2004. London: HMSO, 2004.
British Household Survey 2001. www.iser.essex.ac.uk/ulsc/bhps/ (accessed 8 Feb 2005),
Health survey 2001. www.dh.gov.uk/PublicationsAndStatistics/PublishedSurvey/HealthSurveyForEngland/fs/en (accessed 8 Feb 2005).
General household survey 2001. www.statistics.gov.uk/ssd/surveys/general_household_survey.asp (accessed 8 Feb 2005).
Stevens S. Reform strategies for the English NHS. Health Affairs 2004;23: 38-44.
Wanless D. Securing our future health: taking a long-term view. Final report. London: Her Majesty's Treasury, 2002. www.dh.gov.uk/assetRoot/04/07/61/34/04076134.pdf (accessed 23 Feb 2005).
Improving chronic illness care. Model elements. www.improvingchroniccare.org/change/model/components.html (accessed 23 Feb 2005).
HM Treasury. Public service performance. Department of Health. www.hm-treasury.gov.uk/performance/Health.cfm (accessed 25 Feb 2005).
Grumbach K. Chronic illness, comorbidities, and the need for medical generalism. Ann Fam Med 2003;1: 4-7.
Seddon ME, Marshall MN, Campbell SM, Roland MO. Systematic review of studies of quality of clinical care in general practice in the UK, Australia and New Zealand. Qual Health Care 2001;10: 152-8.
Caminal J, Starfield B, Sanchez E, Casanova C, Morales M. The role of primary care in preventing ambulatory care sensitive conditions. Eur J Public Health 2004;14: 246-51.
Clinicians, services and commissioning in chronic disease management in the NHS: the need for coordinated management programmes. Report of a joint working party of the Royal College of Physicians of London, Royal College of General Practitioners and the NHS Alliance, 2004. www.rcgp.org.uk/corporate/position/chronic_disease_nhs.pdf (accessed 23 Feb 2005).
Berwick DM. Commentary: same price, better care. BMJ 2002;324: 142-3.
Johri M, Beland F, Bergman H. International experiments in integrated care for the elderly: a synthesis of the evidence. Int J Geriatr Psychiatry 2003;18: 222-35.
National Primary and Care Trust Development Programme. Castlefields health centre: chronic disease management. www.natpact.nhs.uk/uploads/Castlefields%20Report.doc (accessed August 2004).
Hutt R, Rosen R, McCauley J. Case-managing long-term conditions: what impact does it have in the treatment of older people? London: King's Fund, 2004.
Roland M, Dusheiko M, Gravelle H, Parker S. Follow up of people aged 65 and over with a history of emergency admissions: analysis of routine admission data. BMJ 2005;330: 289-92.
Lawrence S. Survey: implementation of health IT lags. E-week 2004 Aug 3. www.eweek.com/article2/0,1759,1630833,00.asp (accessed 26 Nov 2004).
Maynard A, Bloor K. Trust, performance management and the new GP contract. Br J Gen Pract 2003;53: 754-5.
Newman S, Steed L, Mulligan K. Self-management interventions for chronic illness. Lancet 2004;364: 1523-37.
Kennedy A, Gately C, Rogers A, EPP Evaluation Team. National evaluation of expert patients programme. Assessing the process of embedding EPP in the NHS preliminary survey of PCT pilot sites. Manchester: NPCRDC, 2004. www.npcrdc.man.ac.uk (accessed 26 Nov 2004).
Meads G, Iwami M. Latin lessons give grassroots insight. Primary Care Report 2003;5: 10-7.
Stuteley H. The beacon project—a community-based health improvement project. Br J Gen Pract 2002;52(suppl): S44-6.(Tim Wilson, general practitioner1, David)
Correspondence to: T Wilson tim.wilson@gp-k84036.nhs.uk
The NHS is waking to the challenge of chronic diseases. Three researchers who have worked in the Department of Health discuss how the NHS might rise to the challenge of better supporting people with long term conditions
Analysis of the British household panel survey (2001), the health survey for England (2001), and general household survey (2002) has given us a great insight into how long term conditions affect people in England.3-5 The data show that:
Around 6 in 10 adults in the household population report some form of chronic health problem;
People with chronic health problems are significantly more likely to see their general practitioner (they account for about 80% of consultations), more likely to be admitted as an inpatient (on average about twice as likely given a particular problem, but up to seven times more likely for cancer), and use more inpatient days than those without (fig 2);
Health care utilisation intensifies with the number of problems reported (the 15% of people with three or more problems account for almost 30% of inpatient days);
Some people are highly intensive users of inpatient services: 10% of inpatients account for 55% of inpatient days, and within this are the very high intensive users, with 5% of inpatients accounting for 42% of inpatient days (fig 3);
People with any long term problem are about twice as likely to be intensive users than those without. Intensive users on average have three chronic problems, and are likely to be found among older people.
Fig 2 Likelihood of respondents to British household panel survey 2001 (n=5500) with chronic problems needing to use health services
Fig 3 Cumulative days in hospital spent by patients admitted as inpatients. Source: analysis of British household panel survey 2001
From this we can deduce three clear messages. Firstly, as does the rest of the world, the United Kingdom has many people with chronic disease—and we need an NHS that supports them. Secondly, people with chronic disease are disproportionate users of the health system. Thirdly, a group of patients, who tend to be older, have multiple long term problems and are spending disproportionate periods in hospital.
The commonest reported problems are those of the musculoskeletal and cardiovascular systems (table 1). Chronic diseases, although often associated with older adults, also affect children. In the United Kingdom, 15% of the under 5s and 20% of the 5-15 age group are reported to have a long term condition. The likelihood of a long term problem increases according to socioeconomic circumstances (fig 4).
Table 1 Prevalence of chronic problems in the British household panel survey, 2001
Fig 4 Percentage of respondents to general household survey 2002 (n=13 000) with a longstanding problem
NHS reform and the challenge of long term conditions
Some features of the NHS sustain support for people with long term conditions. These include well established primary care teams (including community nurses and general practices) and a network of other community providers, including pharmacists and therapists. Crucially, having patients registered with a general practice offers great opportunities for supporting those with long term conditions and also provides patients with an unparalleled certainty about who will coordinate services and act as the final repository of care. For those with more than one condition, this is fundamental.10 However, the variations in care for people with chronic diseases by general practice are currently unsupportable,11 and changes in policy are seeking to reduce these variations.
The NHS is moving towards a system that is highly dependent on the effective commissioning of services by primary care trusts; in effect they are charged with ensuring that patients receive the support they need. As primary care trusts build their skills to more effectively commission care, they can ensure that financial incentives and mechanisms result in delivery of the best care for patients with long term conditions. To support trusts in their commissioning role are a series of financial incentives. Perhaps most significant is the new general practitioner contract, which includes the quality and outcomes framework, a reward system for the management of 10 important chronic diseases. Using an automated payment system based on the electronic patient record, this provides strong incentives for better clinical management of these conditions.
Another financial incentive is payment by results. This fee for service payment mechanism could affect patients with long term conditions in four ways:
Providers of specialist services are more likely to respond quickly to the needs of patients with long term conditions who need episodic care (such as an outpatient visit, cataract surgery, or joint replacement)
Money previously locked in hospital systems can be released for the benefit of community based services; research on the benefits of investing in ambulatory sensitive conditions (like heart failure or chronic obstructive pulmonary disease) indicates that this results in considerable benefit12
Acute trusts will make savings by reducing the length of stay, especially for those patients who occupy beds the longest, who are generally people with long term conditions
It might also have a perverse incentive: encouraging hospitals to increase (or maintain) activity inappropriately or face financial deficits.
The twin issues of reduced length of stay, and the incentive of hospitals to increase activity for patients with long term conditions, means that primary care trusts will have to work hard to balance investment between community based health and social care services, who pick up early discharges, and hospital departments, who see activities decreasing. The trusts can of course engage clinicians in the commissioning process to ensure that patients with long term conditions get the most appropriate care, most notably by giving practices an indicative budget. Another mechanism is to encourage networks of generalists and specialists to become involved in the commissioning process for particular disease areas.13 We are learning more about the importance of involving patients in the commissioning process; patients as co-designers of the healthcare system are potent allies for primary care trusts.
The trusts' ability to commission care effectively, including care for people with long term conditions, continues to be debated. Primary care trusts were established in 2002 and are still relatively immature organisations. Many have yet to make the most of their control of around 80% of the NHS budget. The balance of power within the NHS has resided with the providers of acute services, and the independence of these providers is being reinforced by the creation of NHS foundation trusts, a new kind of organisation managed at arm's length from the NHS. Primary care trusts in many parts of the NHS have found it difficult to negotiate on equal terms with acute services providers, in part because they lack the expertise and information to challenge the people running hospital services. Collaborative commissioning, in which neighbouring primary care trusts agree to work together to negotiate with providers, is being used in some places to address this issue. In parallel, the government is encouraging the trusts to devolve their budgets to general practices so that practices can commission some services directly. These developments have created uncertainty about the future of the commissioning function in the NHS.
Design of the delivery system
The development and use of guidelines will be facilitated in due course by the large investment in the National Programme for IT (information technology). A patient record, accessible across every part of the NHS, will go a long way towards overcoming some of the potential divisions in a pluralistic delivery system. Many other aspects of better support for long term conditions will also be facilitated by the programme: better planning for populations of patients, identifications of their needs, and support for commissioning, including easier monitoring of contracts. These will not be universal for some time, and the implementation will be difficult if the experiences of other healthcare IT programmes are repeated.19
Decision support
The evidence base backing the use of generic programmes to support patients, like the expert patient programme and disease specific self management programmes for conditions like diabetes or chronic obstructive pulmonary disease, is strong.21 Although the expert patient programme is showing mixed results, it is clearly having a major impact on many patients.22 The challenge for the NHS is how to move from a programme that has trained 12 000 patients to one that can support the many millions of patients who might benefit. This poses three questions. Firstly, does the capacity exist to deliver the expert patient programme or disease specific self management programmes on this industrial scale? Secondly, with its limited resources, the expert patient programme has spare capacity (personal communication, Harry Cayton, National Director for Patients and the Public at the Department of Health, England); what will make the "prescription" of self care as routine as the prescription of a statin in heart disease? Further, will routine self care for all be as effective as it is now, in groups who have volunteered? Thirdly, little is known about the sustained effect of these programmes on life long conditions; what reinforcement is necessary?
Community resources and policies
Major reforms in the English NHS—including a massive investment in the NHS as a whole, the potential of effective commissioning, and opportunities opened up by the National Programme for IT—offer obvious benefits to patient with long term conditions. Challenges remain: ensuring commissioning is indeed effective, using incentives such as payment by results, avoiding the risks of NHS foundation trusts pursuing their own interests at the expense of the wider system, and achieving closer integration of service provision. These reforms could benefit patients who have long term conditions, but they carry tensions that could create problems if not properly applied or regulated (table 2).
Table 2 Effects of system changes in the NHS on people with long term conditions
Case management is a target for the Department of Health. If the full potential of the current policy emphasis on chronic diseases is to be obtained, the NHS will need to link case management to more consistent disease management and self management in what amounts to nothing less than a paradigm shift in the way in which services are provided. At the heart of this shift is the need to move away from the acute care model, in which health services rescue patients when they become ill in an episodic manner, to a chronic care model, in which the resources of the healthcare system and communities are harnessed to provide high quality care over time.
Summary points
As the number of people with long term conditions in the United Kingdom rises, the NHS needs to adapt so it can respond to their needs
The NHS is experiencing investment and reform
Programmes already in place (especially case management by community matrons) are supporting people with long term conditions
Many reforms will create tensions in the NHS that, if managed well, will reap benefits for patients with long term conditions
The NHS must carefully monitor progress on supporting people with long term conditions so that it can learn, adapt, and make best use of the available opportunities
TW has been a senior policy analyst in the Department of Health strategy unit and CH has been its director. This article represents the opinions of the authors alone and does not constitute official Department of Health policy.
Contributors: TW did much of the literature search and some analysis, brought together the evidence, and was the lead author of this article; DB did the most of the data analysis and epidemiological work; CH organised and planned the work on long term conditions in the Department of Health and helped write this article.
Competing interests: DB is employed by the Department of Health. CH and TW are occasionally paid to speak and advise on policy matters, including the support of long term conditions.
References
Smith R. Is the NHS getting better or worse? BMJ 2003;327: 1239-41.
Secretary of State for Health. The NHS improvement plan 2004. London: HMSO, 2004.
British Household Survey 2001. www.iser.essex.ac.uk/ulsc/bhps/ (accessed 8 Feb 2005),
Health survey 2001. www.dh.gov.uk/PublicationsAndStatistics/PublishedSurvey/HealthSurveyForEngland/fs/en (accessed 8 Feb 2005).
General household survey 2001. www.statistics.gov.uk/ssd/surveys/general_household_survey.asp (accessed 8 Feb 2005).
Stevens S. Reform strategies for the English NHS. Health Affairs 2004;23: 38-44.
Wanless D. Securing our future health: taking a long-term view. Final report. London: Her Majesty's Treasury, 2002. www.dh.gov.uk/assetRoot/04/07/61/34/04076134.pdf (accessed 23 Feb 2005).
Improving chronic illness care. Model elements. www.improvingchroniccare.org/change/model/components.html (accessed 23 Feb 2005).
HM Treasury. Public service performance. Department of Health. www.hm-treasury.gov.uk/performance/Health.cfm (accessed 25 Feb 2005).
Grumbach K. Chronic illness, comorbidities, and the need for medical generalism. Ann Fam Med 2003;1: 4-7.
Seddon ME, Marshall MN, Campbell SM, Roland MO. Systematic review of studies of quality of clinical care in general practice in the UK, Australia and New Zealand. Qual Health Care 2001;10: 152-8.
Caminal J, Starfield B, Sanchez E, Casanova C, Morales M. The role of primary care in preventing ambulatory care sensitive conditions. Eur J Public Health 2004;14: 246-51.
Clinicians, services and commissioning in chronic disease management in the NHS: the need for coordinated management programmes. Report of a joint working party of the Royal College of Physicians of London, Royal College of General Practitioners and the NHS Alliance, 2004. www.rcgp.org.uk/corporate/position/chronic_disease_nhs.pdf (accessed 23 Feb 2005).
Berwick DM. Commentary: same price, better care. BMJ 2002;324: 142-3.
Johri M, Beland F, Bergman H. International experiments in integrated care for the elderly: a synthesis of the evidence. Int J Geriatr Psychiatry 2003;18: 222-35.
National Primary and Care Trust Development Programme. Castlefields health centre: chronic disease management. www.natpact.nhs.uk/uploads/Castlefields%20Report.doc (accessed August 2004).
Hutt R, Rosen R, McCauley J. Case-managing long-term conditions: what impact does it have in the treatment of older people? London: King's Fund, 2004.
Roland M, Dusheiko M, Gravelle H, Parker S. Follow up of people aged 65 and over with a history of emergency admissions: analysis of routine admission data. BMJ 2005;330: 289-92.
Lawrence S. Survey: implementation of health IT lags. E-week 2004 Aug 3. www.eweek.com/article2/0,1759,1630833,00.asp (accessed 26 Nov 2004).
Maynard A, Bloor K. Trust, performance management and the new GP contract. Br J Gen Pract 2003;53: 754-5.
Newman S, Steed L, Mulligan K. Self-management interventions for chronic illness. Lancet 2004;364: 1523-37.
Kennedy A, Gately C, Rogers A, EPP Evaluation Team. National evaluation of expert patients programme. Assessing the process of embedding EPP in the NHS preliminary survey of PCT pilot sites. Manchester: NPCRDC, 2004. www.npcrdc.man.ac.uk (accessed 26 Nov 2004).
Meads G, Iwami M. Latin lessons give grassroots insight. Primary Care Report 2003;5: 10-7.
Stuteley H. The beacon project—a community-based health improvement project. Br J Gen Pract 2002;52(suppl): S44-6.(Tim Wilson, general practitioner1, David)