Waking up to chronic care.

W e are currently experiencing in the United Kingdom something of a backlash against the recent assertions that the National Health Service (NHS) has something to learn from the large Health Maintenance Organizations in the United States such as Kaiser. Whatever the arguments about the relevance of comparisons between our systems, the Chronic Care Model (CCM) is a transatlantic development that really does deserve our close attention because it is an intelligent and pragmatic approach to restructuring care systems. More than ‘‘disease management’’, it offers a common technology that can be applied across several different chronic conditions. The central role played by the care manager in measuring progress and outcome of care, ensuring follow up, and enabling the ‘‘stepping up’’ or ‘‘stepping down’’ of the intensity of care provided when required according to data systematically collected is a revolutionary concept to many health professionals. This is because the model of chronic illness care in which they were trained and still deliver is actually acute care—managing crises as they happen rather than engaging the patient in selfmanagement activities. I am as guilty of this as the next health professional, having at times in my career relied on haphazard follow up, ‘‘clinical impression’’ rather than systematic measurements of illness severity, disorganised case records, and my own (fortunately good) memory to try and achieve optimal outcomes. One of the major barriers to implementation of system change to promote quality improvement for chronic conditions is the fractured nature of our care pathways which derive directly from the design of the NHS at its inception in 1948. The World Health Organization version of the CCM rightly emphasises the importance of the policy environment (both local and national) in supporting change in many healthcare systems across the world. In the US this level seems to be absent, or at least to amount to not much more than a series of locally driven experiments in changing delivery systems that are often on short term funding. In the UK we do have health policy (rather a lot of it), as do many other developed and developing countries across the world. However, the task of bringing together stakeholders from primary care trusts, mental health and social care, and acute trusts to agree to redesign delivery of care for people with chronic problems such as depression and diabetes can be difficult. We need to try to ensure that those who really need to get specialist care do so, and that effective care management is provided in the context of a coherent stepped care delivery system. But getting people together to work constructively on this task seems often to be beyond the remit of local NHS strategic management. Decision making and responsibility has rightly been shifted from the centre, yet we seem to lack the ability to plan clinical care pathways for populations across primary and specialist care. We have problems meeting the demand for acute care, yet these acute episodes of ill health are often merely acute flare-ups in the course of chronic illness. Crises that could be avoided with better organised and integrated care pathways for managing chronic illness thus end up resulting in potentially preventable admissions. In organisations such as Kaiser where the CCM has been implemented, system change has been easier because of the integrated nature of the organisation. But this model and variants of it have been implemented successfully across the world and across system divides where there has been the will and leadership from both managers and clinicians to make things change. The model has also played a central role in the USA in the Chronic Care Collaboratives in the fields of diabetes, depression, heart disease and asthma, which have been successfully disseminated through a partnership between the Improving Chronic Illness Care Program in Seattle and the Institute for Healthcare Improvement in Boston. The CCM forms the structure around which the evidence for quality improvement for each disorder is organised, and participants are expected to focus on key aspects of implementation of the model during the lifetime of the collaborative. What is crucially important is that the collaboratives have focused on improving the quality of care for chronic illness using outcomes meaningful to clinicians and patients as their target measures rather than taking as their focus economic and managerial targets such as reducing the length of inpatient stay. On the website of the World Health Organization devoted to chronic care, a great deal of very useful information and examples can be found of how the CCM is already being applied across a range of conditions—from alcohol dependence to arthritis—in many countries of the world. For the purposes of a recent journey to the Russian Federation I was able to download material on the model and handouts in the Russian language. The healthcare organisation that I was visiting could not have been more different from Kaiser Permanente. In a basement lecture room with peeling plaster walls my audience—mostly general practitioners and some hospital specialists—were able to see clearly the relevance of the revised model with its emphasis on tripartite collaboration between community, health care, and patient and family. They were keen to set about redesigning care systems, and what they did not possess in monetary resources they made up for in energy and enthusiasm. Perhaps we could learn some important lessons from them too.