From dependence to responsibility

Iain Anderson

A total of 17.5 million people in the UK are currently living with at least one long-term condition. A number of factors including an ageing population, an obesity epidemic and a tendency towards computer games rather than exercise means that this number is likely to increase rapidly in the coming years.

This month’s World Health Organisation’s report, ‘Preventing Chronic Diseases: a vital investment’, highlighted that in the UK alone at least 80% of premature heart disease, stroke and type 2 diabetes could be prevented. Deaths from chronic disease are estimated to decrease by 0.8% over the next 10 years, and diabetes-attributed deaths are likely to rise by up to 25%.

We all need to work together to ensure that existing tools and best practice from throughout the world are rapidly introduced in a manner that is simple, cost effective and most importantly acceptable to patients and their families.

But with the pressure to implement the NHS Connecting for Health programme, why should NHS ICT professionals have long term conditions (LTCs) on their radar?

Economics is high on the agenda. There is clear evidence that complication costs (A&E visits, bed days) can be reduced by promoting a population-wide self-care model, which in turn generates benefits from patients taking their medication more reliably.

Systematic screening programmes that address those most at risk are also a key to addressing LTCs. Up to 50% of newly-diagnosed type 2 diabetes patients already suffer from complications and are likely to have had the condition for several years prior to diagnosis.

Promoting the self-care model (based on an informed patient, family or carer making healthy choices) is one of the most cost-effective interventions ways of managing LTCs. But this challenge cannot be met solely by the NHS. Industry, voluntary organisations, the public sector and individuals need to work together collaboratively to ensure that individuals live effectively with their conditions wherever they are.

Technology will play a key role in enabling this revolution as remote monitoring, pro-active reach, reminder services and e-clinics come into their own. It creates an opportunity to achieve a more positive and cost-effective clinical outcome in ways often more acceptable to the individual, as well as helping to address impending capacity challenge created by increases in LTCs.

Here are three ways in which technology can and already has helped the NHS address these challenges.

Pro-active contact

In pro-active contact, tele-carers work in partnership with the clinical network team, supporting patient groups by telephone, thus encouraging confidence to self manage. As well as the phone, it is also important tp use the internet for the increasing number who see this as their main communication channel.

Generally acceptable to patients, it provides education and awareness but needs to be supported by appropriately structured education programme. It is also important to address language and cultural variations with strong patient advocacy and translation services to increase adoption across diverse communities.

Pro-active contact will augment, not replace, existing structured education programmes.  

Salford PCT – Pro-Active Call Centre Treatment Support (PACCTS)

A randomised controlled implementation over one year was conducted in Salford, Greater Manchester. The trial comprised 591 randomly selected individuals with type-2 diabetes. By random allocation, 197 individuals were assigned to the usual care (control) group and 394 to the PACCTS (intervention) group. Lifestyle advice and drug treatment in both groups followed local guidelines. PACCTS patients were telephoned according to a protocol with the frequency of calls proportional to the last HbA1c level. The primary outcome was absolute reduction in HbA1c, and the secondary outcome was the proportion of patients reducing HbA1c by at least 1%.

[Diabetes Care 28:278–282, 2005]

Remote metric management

Remote metric management can provide healthcare professionals with quality metrics (blood sugar, blood pressure, FEV1, weight) in ‘real time’. This allows more rapid intervention when metrics are moving out of control, thus reducing the risk of complications. Such an approach could lead to reductions in A&E admissions such as hypo- or hyperglycaemic episodes in the case of diabetes.

There is also the additional bonus of electronic logging. This approach, in conjunction with pro-active contact, makes for cost-effective intervention, increasing the efficiency of tele-carers. Work can be focused on those who require intervention rather than simply on sequential calling.

Access can be in various locations to support the requirements of individual patients/carers, and could includes the family home, care homes, pharmacies, schools, prisons and the workplace.

The Whittier Institute for Diabetes, La Jolla, California.

Low income populations have difficulty accessing medical care, and diabetes care requires frequent communication to report self monitoring of blood sugar (SMBG).

Remote monitoring of SMBG and diabetes management by Community Diabetes Educators, assisted by low-cost tele-health devices, resulted in improved glucose control with fewer in-person visits than the usual treatment group. Patients and healthcare professionals both indicated greater satisfaction.  

Medication reminder services

It is estimated that only 50% of prescribed drugs are taken as directed. Much of this is due to lack of confidence or support. This situation does not only have an adverse impact on the patient’s safety but can also accelerate the onset of complications.

Concurrence and reminder services can be supported by several technologies. At the high end of the spectrum, electronic dispensaries in the home can provide alerts to tele-carers for follow up if prescribed drugs are not being taken, or taken too frequently. This type of model supports both pain management and patient safety in conditions such as arthritis.

Reminders can also be delivered by text message, email or phone and initiatives such as SweetTalk have proved successful in supporting children with type-1 diabetes. Clearly, text messaging cannot be an exclusive means of communication, but can be an important arm of a pro-active reach philosophy.

It is clear that technology has an immense role to play in the quest to manage LTCs in a more clinically effective and cost effective way. But with so many other challenges it is difficult to prioritise where resources should be channelled.

In the second article of this series Iain Anderson will examine the future of LTC provision in the UK, looking at widening the responsibility out to the communities and businesses and the issues of linking in with the Connecting for Health programme in England and Informing Healthcare in Wales.