America's healthcare system could help show the UK the way as it grapples to cope with the growing "epidemic" of chronic disease, such as diabetes and obesity, at a time when NHS spending is being squeezed.
There is increasing evidence from the US that the model of group practice, where GPs and hospital consultants work under the same roof, can not only save money but also help extend the life expectancy of people with chronic conditions, in some cases by up to four years.
The suggestion was put forward at a recent roundtable discussion, featuring chief executives from medical associations, doctors and academics in the healthcare sector, which looked at what the UK and US could learn from each other in the management of chronic disease.
The debate, which was hosted by the Guardian and sponsored by Bupa, was held under the Chatham House rule, which allows comments to be reported without attribution to encourage frank discussion.
The roundtable heard that today there are about 15 million people in England alone who are living with a single, long-term medical condition such as asthma, coronary heart disease or diabetes, according to official figures from the Department of Health. The total is rising, as is the number of people who find themselves living with multiple chronic diseases.
There are three major risks for chronic disease that are "modifiable": diet, exercise and smoking. But as lifestyle changes are not being made to the extent they should be, one speaker suggested the vocabulary needs to change: "It's right to call it an epidemic because it looks like an infectious disease and it behaves like an infectious disease.
If we treated it as such we could stop it but we don't because we think there is nothing we can do about it." It was a similar attitude to that taken by people in the big epidemics of the 14th century, he said, when people threw rose petals on the dead bodies during the bubonic plague. "If you look at the analogies between the Black Death and type 2 diabetes they are quite close," the speaker remarked.
'Shared decision making'
But while the demands of chronic conditions on the health service in England is growing, the NHS is looking to save £20bn by 2014 and is facing major reform, following publication this summer of the government's white paper, Equality and Excellence: Liberating the NHS.
The intention is that responsibility for commissioning NHS services will fall to consortia of GPs as primary care trusts and their strategic health authority bosses are abolished. At the same time, the government wants to embed in the NHS the principle of "shared decision making" between patients and their clinicians about their care: "No decision about me without me" states the white paper.
But the concern of those health economists and organisations, representing the interests of patients and service providers, who took part in the debate is whether this new-look NHS, with the power being shifted away from managers to family doctors, is going to be able to cope with the increased demands of chronic disease.
So, can the UK learn from other countries about the way they manage this group of patients?
In the US, group practice was successful in caring for people with long-term conditions because family doctors and hospitals "have a strong sense of mission and clinical leadership", the roundtable, was told.
"Primary and secondary care doctors are in the same space, they are glued together by this mission," one participant said. In addition, the pressure of peer review contributed to making this way of working a success.
A fruitful relationship between GPs, nurses and hospital doctors was also behind another US care pathway designed specifically for patients with diabetes, which has been adopted for the past 15 years by a group of hospitals in Utah. In the Utah model the patient's primary care doctor takes responsibility for continuity of care.
But the relationship between the family doctor, the consultant and the patient is totally different from that which exists in the UK, the roundtable was told. "The consultant is consultant to the physician – not necessarily the patient", a contributor explained, and together the clinicians have developed protocols which "have worked a lot of costs out of the system".
The coalition government, as the white paper illustrates, is determined to put patients at the heart of decisions about their care. Ministers hope that the more involved patients become in the decision-making process, outcomes will improve and NHS costs reduce.
This view was borne out by a recently published London School of Economics report (Bupa Health Pulse 2010), which quizzed more than 12,000 people from around the world about their attitude to chronic disease. It showed that evidence was starting to emerge that self-management can improve patient health and reduce costs.
In the UK, the roundtable was told, one national patient charity for people with a chronic condition, which accounts for 10% of NHS spending, was already taking steps to help patients take more control of their health. The charity is collecting information to create a national league table in order that patients can compare the quality of care.
It is intended that patients will be empowered to manage their own conditions and be in a stronger position to articulate their individual needs.
In the US though, a different approach is being taken to empower patients. The roundtable was told about an American project where nurses "coach" or "nudge" patients in the lifestyle changes they might adopt, which could improve the management of their long-term conditions, potentially reducing the need for hospital readmission. The results of the project revealed that it had reduced hospital stays and health costs.
A similar project is now running in the UK. A speaker said: "It is felt that in America the patients are more motivated because insurance costs are involved. There is this idea that in the UK, patients are not that motivated. But I am not so sure that's right. I think British patients will respond to this [way of working] too."
The UK government's desire to promote shared decision making in chronic-disease management requires the co-operation of GPs, which has been slow to happen. A speaker told the roundtable: "This is about getting the patients to manage themselves but there is a bit of fear out there [among GPs] that we are trying to take patients away." In the US, the roundtable heard, three states have decided to change the law to place a statutory obligation on family doctors to involve their patients in decisions about their care.
Back in the UK, the east of England region has been taking different steps to create a culture of shared decision making. Every patient with a chronic condition has their own personal health plan, which has "self care" running through it. Their care is commissioned according to a pathway "hub" where services are based in the community.
Primary and secondary care specialists work together managing a patient population with a group of conditions according to integrated pathways with "intensive episodic highly specialised care" being managed outside of the hub, a speaker explained.
Focus on value
As the NHS faces £20bn of efficiency savings at the same time that there is an increase in cases of chronic disease, services will have to prove that they are providing value for money. To help address this, the Department of Health last month published its Atlas of Variation in Health Care.
The document includes 34 maps that look at how much money each primary care trust in England spent on specific clinical services in 2009 – including chronic conditions – and links that to patient health outcomes.
The report is significant because as one speaker said: "While we may know what we spend on asthma we don't know what we are getting for it or what asthma care has bought in Liverpool or Manchester." The speaker added that for the past 10 years the most common word in the NHS was "quality" but for the next 20 that will be replaced by "value" with a greater emphasis on outcomes and money spent.
Heath prevention, which stops people developing chronic conditions in the first place, is also crucial if the current epidemic is to be halted. There was some hope from the roundtable that the government's public health white paper, Healthy Lives, Healthy People: Our Strategy for Public Health in England – which comes with a £4bn budget and gives local councils rather than the NHS responsibility for public health – might help.
But there was also concern that the document lacked a national strategy. "The big question is how much can we put things in place when there is no national overview," said one speaker.
While there was no single solution to improving public health and reducing chronic disease it was felt that "society" as a whole, rather than health professions alone, had to take the lead because the public had the power to bring about significant change. One speaker remarked: "The success on banning cigarette smoking wasn't because the [health] profession was leading on it. GPs aren't going to have the strength to go out and shut down their local McDonald's."
Chronic disease is responsible for 60% of all deaths in the world, according to World Health Organisation figures. In the UK the cost of heart disease alone accounted for 12% of the NHS's total expenditure in 2006. Chronic disease rates are expected to continue to rise as UK health spending is squeezed and the NHS is reformed. But this climate of change offers an opportunity for innovation in the management of chronic disease with new ideas coming from within the NHS as well as others from across the Atlantic, which are already being adopted.
At the table
Health correspondent, the Guardian, (Chair)
Executive director, Oxford Health Alliance
Sir Muir Gray,
Chief knowledge officer, NHS
Dr Andrew Vallance-Owen,
Group medical director, Bupa
Dr Jack Wennberg
Founder and director emeritus, Dartmouth Institute for Health Policy and Clinical Practice
Dr Steve Laitner,
GP and associate medical director, NHS East England
Chief executive, Diabetes UK
Director, Nuffield Trust
Professor of mental health and ageing, King's College, London
Managing director, Bupa Health Dialog
Principal research fellow, London School of Economics
Chair, Child Growth Foundation; Spokesperson, National Obesity Forum