We are all aware that the current NHS financial trajectory is unsustainable. With rising demand, in part through our ageing population, the time to act is now, but the question is how.
Cardiovascular diseases, diabetes, dementia and cancer could all be considered 'time bombs' for the NHS. Despite valiant primary prevention efforts, conditions such as heart failure, diabetes and melanoma are all increasing. As such, the current approach is clearly not sufficient and a shift in behaviour is needed. So who needs to take responsibility for this shift and facilitate working towards one integrated system that is driven by quality and is owned by all?
GPs, public health and hospital specialists are already starting to build this 'machine' but the oil and fuel are both still sparse. There is no room for professionals who dig their heels in, particularly given the focus is on quality of care. The answer as to who needs to take responsibility is, of course, everybody and that includes NHS workers, the government and the public. Everybody needs to believe in the need for change and be motivated enough to act.
In terms of an individual's health, determinants of future health (and cost) depend on several actions, or lack of action, over a lifetime. The outcome of these may lead to depression, disease progression and multiple hospital admissions. Motivating individuals to prevent themselves becoming patients, to drive their own disease management and to seek help early to avoid admission are all factors crucial to future-proofing the NHS. Maybe its the public and patients who are the engine and the healthcare professionals who are the oil and fuel.
The CLOUD model for LVSD
This thinking can be applied to most chronic diseases. Consider heart failure, specifically left ventricular systolic dysfunction (LVSD); it is evident that LVSD is often preventable, undiagnosed, increasing, a major contributor to unplanned admission and re-admission activity, and not as well managed as it should be.
Motivating people to be healthy and prevent developing cardiovascular disease in the first place, motivating diagnosed patients to take responsibility for their disease and motivating healthcare professionals to optimise treatment can lead to a better quality of life for patients, a reduction in healthcare expenditure and save GPs' future workload by reducing disease progression.
An approach known as CLOUD is a model that draws together some common sense and clinical guidelines to improve care in LVSD and other chronic diseases. It is a practical framework that should be underpinned by motivation and education for patients and healthcare professionals alike.
CLOUD is an acronym for co-morbidity management, lifestyle management, outpatient monitoring (in primary care), up-titration of drugs and drug adherence.
Optimising co-morbidities has been shown to reduce mortality, admission and morbidity.
Controlling hypertension will of course have other positive health benefits. Depression is common in heart failure and leads to lower life expectancy.
In terms of lifestyle, avoiding NSAIDs, controlling obesity and smoking have obvious benefits too. Ideally patients will be motivated or at least invited to attend regular chronic disease clinics. Here they can be monitored, up-titrated, educated and given crisis avoidance plans in order to seek advice early if they become breathless or rapidly gain weight.
The evidence from national audits suggest patients continue to be poorly up-titrated with ACE-i or ARBs and beta-blockers. If every patient with LVSD was up-titrated to the maximum tolerated dose, the improvement in patients' quality of life, reduction in disease progression (hence future proofing) and admissions would be significant.
A unified approach
It is clear the current approach to prevention and disease management needs a major culture shift, and a shift is already happening. Motivating patients and professionals alike is critical. In commissioning we are often focused on activity and cost, ensuring we reduce waste by only prescribing, testing and referring when it genuinely adds value to the patient. By focusing on the quality of clinical care, the patient pathway, prevention, education and management, the savings should follow. This approach needs the government to work with us, not against us, to encourage people to take their drugs, to lead a healthier life and to take responsibility for their health.
- Dr Thakkar is a GP in Wooburn Green, Buckinghamshire.