The (ex) Policy Maker’s View Chris Ham 31 March 2005

Why the policy on chronic disease? Increasing need in the population International and UK trends are clear Large numbers of people are affected Progress on other priorities created opportunity to focus on chronic disease

Policy builds on the past NSFs for heart disease, diabetes, mental health, older people etc NICE guidance on drugs and technologies Primary care and new GMS Expert patient programme

Policy is still evolving The NHS Improvement Plan NHS and Social Care Long Term Conditions Model Case management and community matrons Self care guidance from DH

Working with Kaiser An un American integrated system High quality outcomes for its population (HEDIS) Risk stratification Much lower bed day use (33% of NHS rates)

6 Population Management: More than Care & Case Management Intensive or Case Management Assisted Care or Care Management Usual Care with Support Level % of a CCM pop Level 2 High risk members Level 3 Highly complex members Targeting Population(s) Redesigning Processes Measurement of Outcomes & Feedback

CHD Bed days per 100,000 aged over 65

Lessons from Kaiser Know your population and focus on the 3 Rs Break down barriers between primary and secondary care Improvement occurs through commitment and not compliance – led by doctors

Caveats The comparisons are not exact (though the bed day differences are large) Is there a substitution effect at work? Kaiser is not perfect and its model is being undermined by the market

Implications for the NHS This will be a key policy priority for the future Some of the systems reforms are not consistent with the policy Foundation trusts and PbR risk reinforcing the acute care paradigm

Implications (2) The NHS must work across all three levels of the triangle Integration of care is essential The risk is that the policy is seen as the responsibility of PCTs and nurses

Implications (3) Targets for bed day reductions (5%/12%) are relatively modest The NHS already has some excellent services e.g. diabetes in Northumberland The best primary care provides a good starting point, and new GMS should help

The next challenge We must fully engage the acute sector and social care We need strong medical leadership at all levels We must promote service and clinical integration, even in the face of contradictory systems reforms

Following up C Ham et al ‘Hospital bed utilisation in the NHS, Kaiser Permanente, and the US Medicare programme: analysis of routine data' BMJ, 2003; 327: D Singh Transforming Chronic Care, HSMC, University of Birmingham, 2005