Disease-specific pathways and hospital-based care are a redundant strategy for the multi-morbidity future, says Integrating Care's Sir John Oldham
Over the next 40 years, most healthcare systems worldwide will face a tsunami of need from people with long-term conditions such as diabetes, chronic airways disease and circulatory diseases. There will be a rise of 252 per cent by 2050, and this is built into existing demography and prevalence. The mathematics are inescapable.
In England now, this group of patients use 70 per cent of activity and cost in the health and social care system. They are disproportionately higher users of health services: they represent 68 per cent of specialist outpatient attendances; 72 per cent of inpatient bed days; 58 per cent of A&E attendances; 55 per cent of GP appointments; and 59 per cent of practice nurse appointments.
The majority of people will not have a single disease, but multiple long-term diseases. Indeed, a large study in Scotland showed that the majority of patients over 65 have two or more long-term diseases, and the majority over 75 have three or more.
The consequences are equally inescapable for most countries. Firstly, if healthcare systems continue to manage people with long-term conditions as they do now, they will not be sustainable. Secondly, the way that a country manages people with long-term conditions will, given the proportion of GDP that this will consume, be a determinant of the competitiveness of that country’s economy. For example, if the US continues its current model of long-term condition management, and given the built-in demographic drivers, by 2065, it will be spending 100 per cent of GDP on healthcare. In one sense, a nonsense statistic.
Some countries with a greater balance between ageing and working populations – particularly in Asia, although this doesn’t include China – will fare better, but for everyone, the status quo is not an option.
Estimates of the NHS funding gap created as a result of this rise in people with multiple needs are between £34–56 billion by 2020. That is an additional 40 per cent or so spend. You also need an additional £10 billion for social care in the same time period. The economic regulator Monitor believes that a rigorous drive on reducing waste could create £10 billion. However, this would still require the health service to produce productivity gains greater than those achieved during the industrial revolution. The track record of the NHS in this regard does not give rise to optimism, but the effort should be pursued.
We need to look elsewhere and, in part, that lies in how we manage people with complex needs and multiple long-term conditions. Currently, we have a health service centred around episodic care; little has changed in its model from the origins that led to that arrangement – the challenge of infectious diseases at the inception of the NHS. That was the 20th century.
The new frontier of healthcare is people with complex needs, and as a system, we need to adapt accordingly. Disease-specific pathways of care and hospital-based care are a redundant strategy for the multi-morbidity future. Our current modus operandi means we can have a Monty Python-esque queue of specialist nurses outside a single person’s house, because they only deal with one disease. But the person inside has several. What’s more, that is just the physical health component; this group of patients usually have coexistent mental health and social care needs. However well-meaning and skilled the care providers are, the fragmentation can never optimise care or prevent wasteful duplication.
This silo mentality is built into how hospitals operate, how policy is generated, and even the research that leads to guidelines and standards. If we always do what we always did, we will always get what we always got. That is why I (and other commentators) have warned clinical commissioning groups that pursuing commissioning for disease-specific pathways (even if there is some integration for that condition with social care) will guarantee little change and unwittingly undermine the viability of the NHS. Indeed, ‘pathway’ is too linear a concept for the web of care that most people with multiple conditions experience.
We need to start with understanding the true issues and what patients and users say: “I want you to treat the whole of me, and act as one team.” This means creating mechanisms for integrated care teams, and pooling specialist knowledge for the customised needs of individuals with multiple problems.
Coordination across mental health, physical health and social care should be the norm. Fortunately, there are people showing the way.
This article originally appeared on NHS Voices – the NHS Confederation's blog for NHS leaders: http://nhsvoices.nhsconfed.org/2013/12/02/disease-specific-pathways-and-hospital-based-care-are-a-redundant-strategy-for-the-multi-morbidity-future-says-sir-john-oldham/