Please note that views expressed in guest blogs on our website are the authors' own and do not necessarily reflect the views of the Nuffield Trust.
The Nuffield Trust today published the evaluation of a new primary care practice, Health 1000, and its work with patients who have multiple long-term conditions. The qualitative outcomes are excellent but, because Health 1000 was unable to achieve the target of a thousand registered patients, the study may not have had sufficient power to demonstrate quantitative benefits.
While the question of what is the best approach for patients with multiple long-term conditions remains unanswered, however, there is considerable learning to pass on.
Building strong local ownership is crucial
The work of setting up a new practice and recruiting patients takes time and can be challenging. Successful recruitment required all primary care practices across three boroughs to be active supporters and co-recruiters. This was not the case, even with enhanced payments to cover any potential financial loss.
An integrated primary care service working with groups of practices that were not separate and requiring re-registration might have developed better ‘buy in’.
Criteria needs some flexibility
Our original premise was based on working with patients with five or more long-term conditions, and improving outcomes and costs to the system. In dialogue with local GPs, other patients with frailty and fewer but more unstable long-term conditions may also have benefited from this type of service. This was not built into our study. To build this flexibility, careful planning is required about how to build comparative groups for outcome data analysis.
Medication management is complex
Without electronic prescribing, the service would not have been possible. While establishing a working relationship, there were challenges working with multiple community pharmacies operating different processes and opening times.
Many of our patients had multiple medicines and complex regimes, plus a need for dosette boxes. Some patients were at the limits of medical treatment, but when attending hospital – particularly as an emergency – would have their regimes tinkered with to no benefit (often by relatively inexperienced staff).
Liaising with other providers is challenging
Each of the three local authorities had different processes and eligibility for equipment. Patients’ eligibility for some of the multiple, established provider services was sometime challenging, with gaps in service and inflexibility. Some providers, while initially accommodating to the service, were less supportive as time went on – suggesting support for integration on the ground is still patchy.
Remote access to integrated care record facilitates integrated care
Access to the patient record – in their homes and remotely – was vital to the delivery of the service. Starting with the limited functionality of a paired-down version on a tablet, and finishing with a web-based, fully functioning record helped us develop and enhance our service. Every patient on joining the programme agreed for their record to be shared with all members of the team, including social care. Indeed, many thought this was already happening.
More complex methods of analysis are required
Evaluation of these new services is not easily undertaken, and rarely suited to the type of randomised control trials commonly used in drug and other intervention trials. This requires a wider dataset of the eligible patients who do not have the intervention to compare and match controls.
While evaluation is more challenging, it remains a vital step in developing and implementing new services.
Health and wellbeing is an important focus
One might think focusing on health and wellbeing in our patients with five or more long-term conditions might be too late, but this was not the case. While many patients were at the limits of their medical treatments, they still had aspirations to live full lives. We were supported by Age UK in providing support for some of these aspirations, including fishing trips, football trips and art groups.
What about a revised, increased tariff for complex patients?
This work was initiated by the Year of Care work, which had identified patients with multiple (greater than five) long-term conditions as heavy users of health and social care.
It seems a single tariff for all patients in primary care may no longer be fit for purpose. As some patients, by virtue of their conditions, are heavier users of health and social care (including primary care), why not recognise that in the payment to practices?
Otherwise in the innovative world we inhabit, newer providers may cherry pick patient groups and distort the primary care provider landscape. The work with Health 1000 can inform the true cost of a year of care for one group of patients – helping to develop a more graduated tariff to support appropriate segmentation for these and other primary care patients.
Great learning exercise
Finally, as a consultant and acute trust medical director, this has been a fascinating and rewarding programme to support – it has been a great learning exercise. I now have an even better understanding of the challenges in delivering new types of care in the current system – challenges we must work to overcome if we are going to work in an integrated way to transform our current illness system into a true health system.
Having worked with such a skilled and committed team locally, I am even more convinced this is possible, provided we enable the teams on the ground to develop and manage the changes required.
*Dr Mike Gill is the Interim Medical Director at Homerton University Hospital NHS Foundation Trust. Please note that views expressed in guest blogs on our website are the authors' own and do not necessarily reflect the views of the Nuffield Trust.
Gill M (2018) "Health 1000: challenges and learning", Nuffield Trust guest comment. https://www.nuffieldtrust.org.uk/news-item/health-1000-challenges-and-learning