the (ex) policy maker’s view chris ham 31 march 2005
TRANSCRIPT
The (ex) Policy Maker’s View
Chris Ham
31 March 2005
Why the policy on chronic disease?
• Increasing need in the population
• International and UK trends are clear
• Large numbers of people are affected
• Progress on other priorities created opportunity to focus on chronic disease
Policy builds on the past
• NSFs for heart disease, diabetes, mental health, older people etc
• NICE guidance on drugs and technologies
• Primary care and new GMS
• Expert patient programme
Policy is still evolving
• The NHS Improvement Plan
• NHS and Social Care Long Term Conditions Model
• Case management and community matrons
• Self care guidance from DH
Working with Kaiser
• An un American integrated system
• High quality outcomes for its population (HEDIS)
• Risk stratification
• Much lower bed day use (33% of NHS rates)
6
Population Management: More than Care & Case Management
Intensive
or Case Management
Assisted Care or Care Management
Usual Care with Support
Level 170-80% of a
CCM pop
Level 2High risk members
Level 3Highly complex members
Targeting Population(s)
Redesigning Processes
Measurement of Outcomes & Feedback
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
CoronaryBypass
AMI Heartfailure/shock
AnginaPectoris
NHS
Kaiser standardised
CHDBed days per 100,000 aged over
65
Inpatient Length of Stay Distribution
0
2
4
6
8
10
12
14
16
Sex/Age Band
Aver
age
Inpa
tein
t Len
gth
of S
tay
NHS IP LoS Kaiser IP LoS NHS IP LoS Kaiser IP LoS
Heart Failure and Shock
Lessons from Kaiser
• Know your population and focus on the 3 Rs
• Break down barriers between primary and secondary care
• Improvement occurs through commitment and not compliance – led by doctors
Caveats
• The comparisons are not exact (though the bed day differences are large)
• Is there a substitution effect at work?
• Kaiser is not perfect and its model is being undermined by the market
Implications for the NHS
• This will be a key policy priority for the future
• Some of the systems reforms are not consistent with the policy
• Foundation trusts and PbR risk reinforcing the acute care paradigm
Implications (2)
• The NHS must work across all three levels of the triangle
• Integration of care is essential
• The risk is that the policy is seen as the responsibility of PCTs and nurses
Implications (3)
• Targets for bed day reductions (5%/12%) are relatively modest
• The NHS already has some excellent services e.g. diabetes in Northumberland
• The best primary care provides a good starting point, and new GMS should help
The next challenge
• We must fully engage the acute sector and social care
• We need strong medical leadership at all levels
• We must promote service and clinical integration, even in the face of contradictory systems reforms
Following up
• C Ham et al ‘Hospital bed utilisation in the NHS, Kaiser Permanente, and the US Medicare programme: analysis of routine data' BMJ, 2003; 327: 1257-60
• D Singh Transforming Chronic Care, HSMC, University of Birmingham, 2005