Leading social care out of the long grass:
Ending the roulette wheel of care:
Alan Milburn’s strident article on health reform presents the urgent need for further reform of the NHS in years to come. Unlike another former Health Secretary, Andy Burnham, who seems to have sacrificed his credentials for opposition for opposition’s sake, having once embraced the reforms to GP commissioning and private sector involvement that he now dogmatically opposes, Milburn accepts that reform cannot be an issue simply left to party-politics.
The rise in chronic illnesses, such as diabetes, together with a rapidly ageing population which will see the number of over 85-year olds double by 2030, means that the NHS is facing a perfect storm. As a result, reform is not an option, it is a must: without it, we will not be able to achieve better outcomes at lower costs, or in Milburn’s words, ‘the new holy grail in health policy’.
What is striking about Milburn’s article is its commitment to the understanding that reform is not an event, but must be a continual progress driven by a quest for excellence, productivity and efficiency. This includes a need for integrated budgets for health and social care, advocated by the Health Select Committee last week, increasing payment by results for healthcare providers, ensuring the frontline take ownership of their services, and above all more competition: ‘Monopolies in any walk of life, whether private or public, rarely deliver operational efficiency or respond well to customer demand … competition may not be appropriate for every service, but if the NHS is to meet the challenges of the next decade it will need more of it, not less.’ Andy Burnham would do well to reflect on this.
The most radical of Milburn’s proposals is his insistence that we have to make patients ‘active participants’ in their healthcare. Stating that studies in the US and the UK have demonstrated that giving patients themselves direct personal control over their budgets, as the government has begun to do with personal budgets in social care, ensures that levels of satisfaction rise and public spending fall. He concludes that ‘hundreds of thousands of patients, particularly those with a chronic condition, should have their own personal state-funded healthcare budget.’
These are ideas which Milburn is right to look at- as he suggests, the evidence and experiences in the US demonstrate individual health savings accounts are revolutionising healthcare and delivering better care at better costs. For instance in Indiana, the introduction of Personal Wellness and Responsibility Accounts, which provide the first $500 of preventative care and encourages enrolees to take responsibility for their healthcare, have allowed 40,000 previously uninsured Indiana residents to register with the plan- all of whom are on incomes below 200% of the federally-set poverty level. Health outcomes are up, and costs are coming down.
Obviously the US is a very different case, but if we are to ensure that the NHS remains able to deliver the best possible care to its most vulnerable patients with chronic illnesses, we need to ensure that personal responsibility becomes the watchword within the service. As other evidence from the US shows, by focusing on those with chronic conditions, so-called ‘super users’, often with high rates of obesity, diabetes, or alcohol dependency and addiction, estimated to be around 15-20% of the population who cover 80% of all healthcare costs, healthcare dependency can be reduced and huge savings can be made- to be reinvested in a better service .
With an older population that will be more dependent on care than ever before, tackling the issue of personal responsibility, neglected for too long, is today’s challenge to ensure the NHS’s survival for tomorrow.
New article on the NHS for the Telegraph, on the problems implicit in an ageing population:
Following on from my article on Conservative Home yesterday, here are the full results of my Freedom of Information requests:
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.
The Prime Minister’s announcement yesterday about opening up access to medical data will help drive future innovation in the NHS, and bring about greater opportunities for scientific research.
In the light of this, I have written an article for the Daily Telegraph on the benefits of extending the use of technology and data in the National Health Service: