Everyone agrees that the future of healthcare lies in patients managing their own conditions outside the hospital system. What are the barriers to realising that vision, and how can the pharma industry help?
As the population ages and the prevalence of long-term conditions (LTCs) increases, everyone is agreed on one thing: the healthcare of the future cannot be focused primarily on hospitals and acute interventions. Primary care and social care systems need to collaborate in building a new healthcare model in which the norm is patients managing their own medical needs in the context of their everyday lives. This model overrides the differences between politicians, clinicians and industry: it’s the only game in town.
However, working towards the new care paradigm is not simple. ‘Leave well alone’ is deeply ingrained in the thinking of patients and doctors alike. The habits of self-monitoring and self-medication are difficult to teach, and the concentration of expertise and resources in hospitals is a self-perpetuating pattern. Everyone is afraid that healthcare in the community will mean isolation and neglect.
For the pharmaceutical industry, the challenge is complex. How does it make its drugs more user-friendly, easier for patients to plan, administer and combine? The challenge goes to the heart of its sales model: as patients become their own doctors, not only the sales messages but the products themselves and the way they are used have to be subtly modified. The underlying model is no longer a reaction to symptoms, but the development of a proactive and dynamic care plan.
It’s not about turning the patient’s home into a miniature hospital, it’s about making healthcare a normal part of life – and that’s a fundamental change in our medical culture and our social thinking. The benefits of such a change to the NHS are clear: reduced costs, fewer hospital admissions, fewer patients trapped in long-term secondary care. So are the benefits to patients: greater control over their own health, greater self-confidence and higher expectations of life.
Three steps to homecare
Even Jeremy Hunt, perhaps the least medically aware Health Secretary in a generation, is talking seriously about building home-based healthcare. In a recent speech to the King’s Fund, Hunt said: “Getting the best possible care outside hospitals means we enjoy higher quality of life, spend fewer days in hospital and keep people happy, healthy and safe at home.”
That’s not just a clinical ideal: the growing numbers of elderly and chronically ill people in hospitals and care homes simply because there is no other solution is a serious problem for the health economy and for society.
There are three essential steps to community-based healthcare, Hunt said, and these are concrete priorities for the NHS. The first is “moving to proactive primary care”. By 2016, there will be three million people in the UK trying to manage three serious, incurable LTCs. The existing system of GPs and district nurses is not adequate to meet these patients’ needs.
Hunt proposes that there should be a named GP for each vulnerable elderly patient. From April 2014, the named GPs will be responsible for ensuring the patients “have proper care plans and are supported to look after themselves”. That means maintaining proactive contact with patients, and for that to be feasible “we need a dramatic simplification of the targets and incentives imposed on GP surgeries”.
Echoing former NHS Confederation leader Mike Farrar, Hunt noted that would mean transferring funds from secondary to primary care.
The second key step is “the integration of the wider health and social care systems”. This will be supported by a £3.8 billion “integration transformation fund” in 2015/16. “Local authorities and the local NHS will have to commit to joint commissioning, better data sharing, seven-day working in health and social care, protecting social care services and having an accountable lead professional for integrated packages of care.”
Finally, Hunt highlighted the importance of electronic health records for ensuring that acute services have immediate access to patient data built up through their primary care history. “It is shocking that when a vulnerable older person is admitted to A&E that hospital typically knows nothing about their medication or medical history.”
Community-based healthcare must provide an effective context for acute interventions in order to minimise the need for them.
The house of care
The recent King’s Fund report Delivering better services for people with long-term conditions outlined the organisational task of “building the house of care”: creating a workable service delivery model for home-based care for the elderly and the chronically ill. Crucially, this model assumes an active role for patients, and therefore demands “collaborative personalised care planning”.
The report structures the ‘house’ metaphor: one wall is “the engaged and informed patient”, another wall is “the health professional committed to partnership working”, the roof is “organised systems and processes”, and the floor is “the local commissioning plan”. This model implies a shift from “a disease-focused, fragmented model of care” to one in which people with LTCs have “a central role in managing their own care”.
The new paradigm requires NHS England to “model the care planning approach through specialist commissioning,” while CCGs and primary care teams need to shift from “the current episodic approach” to one that is “anticipatory and planned”. A core aspect of enabling that shift is to “monitor the extent to which patients are engaged in decisions, have personalised care plans, and receive coordinated services and appropriate support for self-management”.
The report concludes that the “house of care” is “a complex delivery system with primary care as its cornerstone and personalised care planning at its heart”. Such a system “is within our grasp”, but requires “a coalition of the determined”. They’re not kidding. Achieving this transformation in the context of the current NHS reforms, whose trend is clearly towards greater fragmentation of primary care between competing service providers, is a serious challenge.
Making the drugs work
The pharmaceutical industry has a major part to play in the shift towards home-based care. Ongoing drug regimes need to be more easily manageable, sustainable and intuitive for the patient. Key issues include monitoring, drug delivery, sideeffects, and compatibility of medicines for different conditions.
Monitoring of LTCs is essential for dose adjustment. Few chronic illnesses stay the same: most deteriorate progressively, and also show seasonal fluctuations – heart disease may need more medication in the winter, diabetes in the summer. Drug companies can work in partnership with medtech companies to pair therapies with technologies for disease monitoring. Some companies making diabetes drugs, such as Lilly and Novo Nordisk, also make blood glucose monitors to guide dose adjustment within day-to-day control.
Telehealth systems, whereby the patient’s vital signs are transmitted automatically to a call centre providing nurse support, are currently being widely adopted within the NHS. Other electronic systems are in the pipeline, including systems for basing decisions on complex disease analytics (such as the epilepsy management system co-developed by UCB and IBM). Making medicines easier to take improves adherence, and thus can significantly improve outcomes across a patient population. That might mean, for example, providing fewer tablets, smaller tablets or liquid formulations. Combination drugs, insulin pens, insulin belts (implantable devices that potentially combine monitoring with dose adjustment), and inhalable and solid form drug formulations (with corresponding delivery devices) are all growth areas in drug delivery.
The NHS ‘yellow card’ system, backed up by effective GP-patient dialogue, provides a route for identification of medicine side-effects. However, it only reliably captures evidence of serious problems. Patients are likely to keep quiet about minor side-effects, especially where symptoms are embarrassing (such as sexual or gastric dysfunction).
However, as patients become more actively involved in medication decisions, side-effects – a perennial theme on online patient forums – will play a greater role in their choices. A drug may get the red card before the manufacturer has even seen the yellow card.
Too many patients are being treated for LTCs whose main cause is medicine side-effects, whether reversible (erectile dysfunction caused by anti-depressants) or not (IBS caused by long-term use of NSAIDs for musculoskeletal pain). In addition, too many patients with more than one LTC and their different drugs are not compatible – which may be a much a surprise to their GP as it is to them.
The King’s Fund report notes: “Multimorbidity poses additional challenges, as the primary care QOF, most clinical guidelines, and the most common IT systems and datasets are structured around single conditions.” The underlying issue is that, for ethical reasons, drugs are not tested on patients with multiple LTCs.
However, multiple LTCs are increasingly normal in older patients – and the compilation of post-hoc data on medication interference is often belated and unhelpful.
To help the home-based care model become a successful reality, pharma needs to work with healthcare providers and patients to change the way that drugs are used and experienced – and to work with technology partners to provide medicines in the context of an informed, dynamic strategy for patient care.