When it comes to the NHS, there is one certainty all commentators can agree upon. By 2050, the NHS will face unprecedented demand: with an ageing population which will see us living longer, pressure on its services will be immense. The status quo cannot hold. Change, as every political party knows, is not only necessary but vital if we are to ensure that the NHS remains free at the point of delivery, regardless of the ability to pay.
Each day, 1.5 million patients are treated by the service; in a month, 23 million will visit their GP surgery. Yet it remains startling that we do little to record who in particular is coming through the NHS’ doors and how frequently they do so. The truth is that, until we begin to seriously analyse who is using the NHS and why, the service will struggle in future to deliver targeted high-quality healthcare within the constraint of its current resources.
The problem of measuring demand is nothing new. But we can learn important lessons from elsewhere. Camden is one of the poorest cities in the USA, with nearly 95% of the population eligible for Medicaid assistance. By 2007, its hospitals were facing a crisis of overcrowding in accident and emergency departments. The situation became unsustainable, yet it took police reform to begin a healthcare revolution. Jeff Brenner, a physician in Camden, joined the board of a new police reform commission. It opened his eyes to new ideas, such as former New York Police Commissioner William Bratton’s Compstat approach of mapping crime and focusing resources on hot spots.
Brenner transferred this approach to Camden’s healthcare, creating his own Healthstat maps. 387,000 records for 98,000 patients were analysed. For the first time, the location of where patients were coming from were revealed. The results were startling. 80% of the total healthcare costs were generated by just 13% of these patients. One patients was even admitted to hospital 113 times in a single year. Taking the top 1% of patients who were most frequently admitted to hospital, Brenner’s team, the ‘Camden Coalition’, were able to reveal that this tiny group of 1,035 patients made 39,056 hospital visits over five years, accounting for 10% of all admissions, generating charges of $375 million- 30% of Camden’s total medical costs.
It became clear that if these so-called ‘super users’ were effectively treated, preventing their readmission, then costs would also fall. The mission was clear: find the patients with the highest medical costs. If Brenner could improve the quality of total care, he could limit the dependency on emergency room use, reducing costs to the system. In 2007, Brenner launched the Citywide Care Management System with this objective. A software programme was purchased, linking the three hospital databases using name, address and date of birth. To begin with, he gathered together social workers and A&E doctors and revealed the patterns he had found, explaining the cost statistics of that most expensive 1%.
What kind of patients were the Camden Coalition seeking out? The first person the team treated was a man in his mid-forties, with severe congestive heart failure, chronic asthma, uncontrolled diabetes, hypothyroidism, gout, and a history of smoking and alcohol abuse. He weighed five hundred and sixty pounds. In three years, he had spent as much time in hospitals as out. When Brenner met him, he was in intensive care with a tracheotomy and a feeding tube, having developed septic shock from a gallbladder infection.
Brenner visited him each day. As he began to learn his life-story, which included a combination of poor health, alcohol and drug addiction, living in a welfare motel, Brenner had figured out a few things he could do to help. Some of it was simple. He realised that the plans and prescriptions the specialists had made for the patient’s many problems did not always fit together. Teaming up with a nurse practitioner who could make home visits to check blood-sugar levels and blood pressure, he taught the patient, who had little clue about what medications he was taking, what he could do to stay healthy.
A lot of what Brenner had to do went beyond treatment. He enlisted a social worker to help the patient apply for disability insurance, so that he could leave the chaos of welfare motels, and have access to a consistent set of doctors. The team encouraged him to find sources of stability and value in his life. They got him to return to Alcoholics Anonymous. Above all, the greatest challenge the team faced was not ill-health, but hopelessness.
But change did come. Four years on, the patient had gone without alcohol for a year, cocaine for two years, and smoking for three years. His diabetes and congestive heart failure were brought under contro. He lost two hundred and twenty pounds. If he falls, he can now get up by himself rather than calling for an ambulance. There is no miraculous turnaround to primary care. But through care, and perhaps most importantly patience, results do happen.
Now the team actively seeks out clients- unlike most healthcare systems, including the NHS, where patients simply present themselves, often when their condition is already advanced. The Camden Coalition was able to work with 36 super users in its original programme, who alone averaged $1.2million in costs each month. After the intervention programme, charges fell by more than 56% while the number of hospital visits fell by 40%. And for every dollar spent on the intensive case management programme, monthly hospital costs in Camden fell by $55.
We need a similar ‘care revolution’ in the NHS, creating our own health maps to identify where help and care is needed most. For cost is directly linked to care. The effects of bad care can quickly be measured and defined by the number of patients admitted to A&E. Brenner himself remarked, “Emergency room visits and hospital admissions should be considered failures of the heath-care system until proven otherwise.”
The lesson for our NHS is simple. If we can deliver better care to those that need it most, the overall cost to the system will come down. With demographic changes stimulating ever greater demand, the case for a revolution in care needs to be made now.