The UK’s healthcare system has undergone a number of wide-ranging reforms in the last decade and more are planned for the years ahead. In order to help prepare for future policy changes, The Health Foundation has partnered with The Commonwealth Fund to provide fellowships for the rising stars of healthcare in the UK to spend a year in the US examining its healthcare system and learning more about healthcare policy.
Derek Feeley, who is Director of Healthcare Policy and Strategy at the Scottish Executive’s Health Department, is a recent Harkness/Health Foundation fellow. He has been working with leading health policy experts in the field of chronic disease management, to explore how healthcare policy can be developed to provide better quality care for patients in Scotland.
Chronic diseases are prolonged conditions, such as asthma, congestive heart failure, diabetes and hepatitis, which often do not improve and are rarely cured completely. They can have a serious impact on people’s physical, emotional and mental health, often making it difficult to carry on with daily routines and relationships. However, in many cases, deterioration in can be minimised by good care. This requires a more active approach, both from healthcare providers and professionals, and from patients themselves.
2020 vision
Entitled ‘Developing health services for 2020’, Derek’s project looked at how to deal with increasing complexity as more and more people get multiple chronic diseases. “The traditional methods we use to manage chronic disease are single disease focussed,” Derek says. “I was asking the question ‘do these remain appropriate for highly complex cases?’”
The project looked at a relatively small group of people, one per cent of the population, who consume close to 20 per cent of NHS resources. These are the people who, through no fault of their own, are repeatedly admitted to hospital on an emergency basis and take up a huge amount of the health service’s time, effort and money.
“I started off by looking at whether the existing chronic disease models met the needs of these patients,” Derek explains. “I then looked at programmes run by Kaiser Permanente and the Veterans Health Administration, which were specifically designed to deal with this patient group, and tried to identify what we might be able to apply in the UK to enhance what we’re doing.”
Primary function
One of the key issues Derek identified was the placing of responsibility for managing complex cases in primary care. “Some of the models trialled in the UK tend to do this to general practice, whereas the successful models I looked at in the States were doing it in partnership with general practice,” he comments. “There was also an issue about the combination of skill sets in the multi-disciplinary teams that had been set up to manage these patients that seemed to me to be effective.”
Another key finding was that all the models that currently exist underplay the role that carers can play in managing complexity and chronic disease. “Carers don’t really get a mention at all,” Derek says. “Neither of the programmes I saw in the States had a significant input from supported carers but there’s good evidence from elsewhere that they can make a big difference.”
Derek concluded that there were a number of improvements that could be made to current models for managing multiple chronic diseases, for instance by revising guidelines to make them simpler.
“In the NHS at the moment, for example, there’s an excellent 180 page guideline for GPs to use with diabetic patients,” he says. “But if an elderly patient turns up in a GP’s surgery who has diabetes, chronic obstructive pulmonary disease, perhaps a heart condition and just struggles with the normal activities of daily living, then a 180-page guideline on diabetes probably isn’t what the GP needs. What might be better is a single page of A4 that says ‘here are ten things you might consider doing for this patient’.”
Space and time
For Derek, the Harkness/Health Foundation fellowship provided an unrivalled opportunity to devote time and space to look at a single issue. “There’s no way in my current job I would have been able to free up enough time to do what I did,” he says. “There’s also the network of contacts that you’re able to build up. You get access to acknowledged experts in the field and the capacity to contact these people continues even after your fellowship ends.”
The collaborative nature of the scheme was also a major benefit. “You get insight from your colleagues too and that is much more valuable than if I simply made my own way to the States,” Derek says.
Finally, Derek’s fellowship gave him an insight into the realities of the US healthcare system. “It was good to be able to put into context what I had read about the US healthcare system,” he says. “It’s a great opportunity to get behind the rhetoric of US and UK healthcare and actually start to understand some of the similarities and some of the differences.”
11 January 2007