We always hope that the products of the European Observatory will be relevant to policy makers. One way we try to ensure that they are is by involving people who will have to use them at all points during their development. A crucial episode in the production of our books is the authors’ workshop, in which those contributing to the books present advanced drafts of their material to colleagues in governments and international agencies. A few weeks ago (I’m really behind with the blog…) we held the workshop to discuss our forthcoming volume on the management of chronic diseases. The project is led by my colleague Ellen Nolte. It was a fascinating two days, as we were joined by contributors from Australia, New Zealand, Canada, and many parts of Europe.
Chronic diseases will be the greatest challenges that health policy makers will have to confront in the decades to come. People are living longer but as they age they are accumulating increasing numbers of chronic diseases. A typical 85 year old might well have some osteoarthritis, some chronic airways disease, type II diabetes, hypertension and perhaps a touch of Parkinsons Disease. They can expect to be on five or more different drugs, in a combination that has never been tested together, and certainly not on older people with multiple disorders, precisely those least likely to be included in randomised controlled trials.
Fifty years ago, there was little that anyone could do about many chronic diseases. There were two exceptions: diabetes, following the isolation of insulin by Banting and Best in 1922; and heart failure, treated by digitalis obtained from Dr William Withering’s extracts of foxgloves. It was only in the 1960s that modern pharmaceuticals became available. Thiazide diuretics were later joined by beta blockers, bet sympathomimetics, ACE inhibitors, and many others. Steadily, at least in industrialised countries, death rates from many common conditions began to fall.
Yet even today, there is still a long way to go. As Ellen Nolte, Chris Bain and I have shown, most recently in a paper in Diabetic Medicine, death rates from common diseases such as diabetes are very much higher in some otherwise comparable countries than in others. One of the worst performing countries is the USA which, despite spending enormous sums on health care, consistently achieves very poor outcomes.
Given this fact, it is hardly surprising that many of the more innovative ideas for managing chronic diseases have come from the USA. Perhaps one of the best examples is the Chronic Care Model, developed in Seattle, but there are also several similar approaches, albeit all variations on the same theme. We have found the Chronic Care Model to be very helpful in conceptualising the management of chronic disease, highlighting the importance of support for self-management, redesign of health systems, information systems, and better clinical decision-making. But do these approaches deliver what they promise? In fact, the evidence is quite equivocal. Clearly, they can work in the best circumstances but there is rather less evidence that they bring real gains when rolled out into the real world. The most recent example of where these schemes failed to deliver what they promised was the evaluation of the application of the American Evercare scheme in the English NHS. Now as I have said often before, it is relatively easy, at least in theory, to achieve improvements in outcomes of chronic disease in the USA. Just adopt a European health care system…. any system will do. They all achieve far better outcomes. So why one would think that a US system would perform better than that already in place in England was rather a mystery (except, of course, when one remembers our Prim Minister’s fawning admiration for all things American). Now this should not for one minute be seen as anti-Americanism on my part, simply a call for a more balanced perspective.
The idea of the Evercare scheme was that frail elderly people would receive intensive, targeted services that would prevent a deterioration in their condition ad thus reduce the rate at which they were admitted to hospital. It results in more services being provided, which is probably good, but not a reduction in admissions.
This led us back to thinking about why these schemes have come about. Maybe, rather than a response to rising levels of chronic disease, they are instead a response to the contemporary fragmentation of health care? In the old days, a community in the UK would be served by a small number of general practitioners. Those GPs would know their patients intimately. They would also know their families, their jobs, their relationships, and how they spent their leisure time. They didn’t need complex information systems because they kept it in their heads. Now to be fair, there was a lot of information that they did not have, such as laboratory results. But maybe the patient was more concerned about how their illness affected what they could do than he or she was about the precise value of their blood cholesterol.
There is no doubt that the amount of information collected on patients is far greater than anything that existed in the past, especially in the UK where the government has an appetite for data, regardless of whether it means anything, that has not bee seen since the demise of Gosplan, the Soviet state planning organisation. But does the health professional helping a patient to manage their multiple diseases know as much relevant information as his or her predecessor before computers were in common use. I’m not so sure.