NHS Review (February 2005)

Managing Long Term Conditions (continued)

(Published 1st February 2005)

Ideas from the United States around so-called 'managed care' began to increasingly influence government thinking on the management of patients with long-term medical conditions (LTC) a couple of years ago as the US experience seemed to have shown quite clearly that actively treating patients 'upstream' can reduce costs 'downstream'. Two US managed care organisations (Kaiser Permanente and United Healthcare Group) were thus invited to the UK to run PCT pilots using their programmes for LTC. The UHG Evercare pilot programme started in the UK in April 2003. Evercare is a healthcare improvement programme developed to improve the quality of care for vulnerable older people. It involves the use of specially trained nurses to identify and monitor at risk people so that treatment can be given before a visit to hospital is needed. In the US, this programme has reduced hospital admissions by 50%, with more care being provided in the community instead. Key is the use of advanced primary care nurses and the better co-ordination of pro-active care for older patients. The nine PCTs that have been running the Evercare pilots are Bristol North, Bristol South, West Halton, Luton, South Gloucestershire, Walsall, Northampton, Wandsworth and Bexley Care trust. The PCTs that have been running the Kaiser pilots are Blackpool, Eastern Birmingham, Solihull, the East Sussex PCTs, Northampton, St Albans & Harpenden, Taunton Deane and Watford and Three Rivers

Then in early 2004, the Department published Improving Chronic Disease Management, its dissertation on CDM along with Chronic disease management - A compendium of information. The NHS Improvement Plan then described in detail what the brand new policy on CDM (LTC) would be. The NHS Improvement Plan is in effect the NHS Plan now rolled out to 2008 and a document that local sales teams should be aware of. This policy document sets out the case for the new CDM (LTC) strategy and restates the benefits - fewer emergency and inpatient admissions, slowing the progression of disease, personalised care, care closer to home, etc. It also sets out the case for 'community matrons' (advanced nurse practitioners).

This very high profile of LTC was then further reflected in the public service agreements (PSAs) agreed between the DH and the Treasury in 2004 as part of the Comprehensive Spending Review for the next three years. One key PSA is about trying to make sure that those older folk most at risk with chronic conditions are cared for effectively in primary/community settings through proactive personalised care plans - this being backed by an explicit target of a reduction in emergency inpatient bed days by 2008. Certainly the new Treasury target seems to very much support a major policy shift from acute care towards primary care over the period 2005-10 - a major sea change in policy away from the long standing ministerial fixation with elective acute care. This was all consolidated in National Standards, Local Action setting out the targets and standards for the NHS over 2005-8. Once more LTC features quite heavily.

The DH has thus made LTC a key part of the NHS's strategy for the next 3 years. What really does seem to have hit home in the Department is the finding that some 5% of patients account for 42% of overall inpatient days, with many of these patients having multiple co-morbidity (26% of patients have 3+ problems). Also the numbers of people with chronic disease are growing all the time and now place a significant disease and resource burden on the NHS - some 80% of all GP consultations are for chronic disease. Mental health is also in this pot and both HIV/AIDS and cancer now need to be considered as chronic diseases. The position thus being taken by government is that this situation is now unsustainable and that the NHS can no longer afford to ignore the root causes of chronic disease as this is consuming more and more resource. As far as the government is concerned then, we are at some kind of 'tipping point' as regards the need to improve the management of chronic disease and that a more systematic approach is now urgently required.

So first off the DH wants the NHS to tackle those patients with the most complex healthcare needs by a much more pro-active and aggressive (Level 3) case management approach. This model of care will be adopted by every PCT between 2005-2008 and is essentially a 'radar approach' in terms of identifying the 'frequent flyers' (about 250K people = @ 9K/SHA). These are mostly elderly patients with complex multiple co-morbidity who account for the high proportion of the unplanned admissions, and where an advanced nurse practitioners will be proactively used. Below this level comes a much larger group of high-risk patients (Level 2) where better disease management is required. This is particularly where the nGMS QOF fits in, with disease registers and a much more proactive approach to patient management. The NSFs and NICE guidance also interweave in here too. And below Level 2 comes the vast majority of patients where more active self-management is envisaged at Level 1. So now the Expert Patient programme, again based on US ideas, is being expanded to include all 17.5m people with a chronic disease by 2008. Early results do show that taking part in the pilots reduced patient visits to GPs by 9%. Most interestingly, a 10% increase in taking prescribed medicines was recorded! The programme is really quite simple - patients attend six weekly meetings to help to make them more 'empowered' as regards their long-term medical conditions. Trained facilitators with chronic disease are used. But the availability of funds seems to be a bit of a problem so there may be a major opportunity here…

The very latest guidance from the Department on the management of LTC was published last month. Supporting people with long term conditions: an NHS and Social Care model to support local innovation and integration sets out a 'bespoke' NHS and social care model and the new LTC 'blueprint.' Although much of the content has been recycled from previous publications, there are a useful number of case studies, and this is a must read document for Regional Managers. NHS and social care organisations will now have to begin implementing this model and get on and assign individual community matrons to the most vulnerable patients with highly-complex multiple long-term conditions. These nurses will be at the heart of the new system and the DH is committed to having 3000 in place by March 2007. PCTs will also have to establish multi-professional teams that can identify all of the people in their area with a single serious long-term term condition and assess their health needs as early as possible. PCTs also have to make sure that all folk with long-term conditions are educated about their health and are encouraged to manage their own care more effectively. So also published last month was Self care - A Real Choice. This guidance provides some ideas on how to support self care. The NHS Confederation has particularly welcomed this new guidance. Jo Webber, policy manager at the NHS Confederation, said: "We are pleased that the new guidance meets so many of the recommendations we campaigned for in the '17 Million Reasons' manifesto. 17 Million Reasons is at http://www.17millionreasons.org/ and is well worth a read. The new model also links to the NSF for long-term conditions, to be published next month. This NSF, whilst focussing on neurological conditions, will also draw out generic lessons for care, treatment and support services and a more prescriptive approach to sharing and pooling of budgets between PCTs and social services departments seems set to feature. See Supporting people with Long Term Conditions.

What does all this mean?

PCTs will now have to introduce more effective LTC/CDM systems. With a DH PSA and a NHS target on LTC/CDM, PCTs will just have to deliver on this so the opportunities to partner with PCTs must be significant. Unmet need will likely to be discovered through more widespread use of disease registers required by nGMS and one could suggest that there are now absolutely fantastic opportunities to help PCTs out here… .

Some other areas of interest this month
As well as a main feature each month, we will also be picking up on a few other areas for you.

DH Stuff

NHS Finance

The NHS appears to be struggling to plug a £500m black hole in its finances - with parts of the country embarking on service cuts, recruitment freezes and redundancies as Finance Directors frantically try to achieve balance by the end of March. But it was ever thus…. So over the next two months drug budgets will be under intense pressure as both PCTs and NHS Trusts seek savings to reach financial end of year balance. It will be a difficult time to introduce new drugs…

Payment by Results

The DH has announced that it is to restrict the implementation of the new financial system to cover only waiting lists from April, and not non-electives, outpatients and A&E in the non-Foundation Hospitals who come on line then. However although the scope of PbR has been changed for 2005/6, the Department is keen to point out that the overall implementation timetable remains unchanged with 90% of hospital care covered by 2008/9. The delay in PbR means that the early wave foundation hospitals pull further ahead in their 'learning' and one reason why hospital sales teams should develop improved links with these hospitals. Sales Teams will need to discuss the implications of PbR and have some understanding of the new financial flows. More on this later in the year.

NHS Foundation Trusts

Monitor (the Independent Regulator of Foundation Trusts) has authorised five new NHS Foundation Trusts. This is the third group of applicants to be authorised, bringing the total to 25. See Monitor Press Release. A fourth group of 10 applicants remains under consideration, with a target date of the 1st April. This will take the numbers to 35. And another 32 trusts have had their preliminary applications accepted by the DH. These would be expected to commence from spring 2006. See DH press release 2005/0017. Sales Teams need to discuss the implications (a SWOT?) of the arrival of a NHS Foundation Trust on their patch. More on this later in the year.

PCT Stuff

PCT Mergers

As the general election approaches, many commentators are predicting that PCT numbers are set to fall 'dramatically' through the next parliamentary term, going down possibly to less than 200. But such mergers are not the only option open to PCTs and some are opting to organise themselves in 'confederations' and clusters.' The number of PCT Commissioning Consortia also continues to grow and local sales teams need to track all these developments carefully.

PCT Partnerships

Nottingham City PCT is to appoint a Pharmaceutical Industry Liaison Manager (see www.nottingham.nhs.uk). Blurb from their ad says, "Nottingham City PCT has adopted a strategic approach to working in partnership with the pharmaceutical Industry. We have secured sponsorship from a significant number of companies to fund the appointment of this post….You will manage our relationships with individual companies." In a document entitled A Strategic Approach to Working in Partnership with the Pharmaceutical Industry we learn that the post holder will be gatekeeper and first point of contact for all Industry contact with the PCT, whether companies are involved in the initiative or not. Last year Durham Dales PCT appointing a similar post and this post is specifically mentioned in the document. These new posts are clearly a brand new kind of customer.