Seminar 5: New models for chronic disease prevention and management

On 18 January 2011, Simon Stevens gave the fifth of C3’s International Breakfast Seminars, on the subject ‘New models for chronic disease prevention and management: insights from across the Atlantic’.

Simon is president of the global health division at the UnitedHealth Group (which manages health care for 75 million people in 50 countries). He was previously Prime Minister Tony Blair’s health adviser at 10 Downing Street, and before that a senior NHS manager. His topic was new US approaches to tackling chronic disease that might be relevant to Britain. The seminar was held at the House of St Barnabas, Soho, London.

Simon started by pointing out that, although chronic conditions are often thought of as a problem of the richer industrialised countries, in fact the majority of chronic disease-related deaths over the next 20 years will occur in low- and middle-income countries. There are important opportunities for mutual learning between those settings, and the US National Institutes of Health and UnitedHealth are now co-funding 11 major collaborations in developing countries, testing new models for prevention and early intervention, such as salt reduction in rural China, indoor air-pollution reduction in sub-Saharan Africa, new chronic disease surveillance techniques in India, and the use of community health workers in Central and South America.

Nevertheless, Simon had been asked to focus his presentation on the US–UK learning opportunities. These would be occurring against the backdrop of an unprecedented slowdown in NHS funding growth over the next four years. He said that, given their importance as a driver of health-care spending, how well the NHS modernises its response to chronic conditions will be a key determinant of how well it emerges from this budget squeeze.

Simon reported that both the United States and United Kingdom have significant chronic disease-related challenges. It was true that the United States has seen meaningful reductions in tobacco usage (on one measure, down from 29.5 per cent in 1990 to 17.9 per cent in 2010), but tobacco still causes perhaps a fifth of US deaths. US infant mortality, cancer and cardiovascular death rates are all improving, as are potential years of life lost; and some jurisdictions such as New York City have taken major steps in primary prevention of chronic disease. But there are large geographical and other differences and critically, obesity is up from 13 per cent to 28 per cent of US adults over 20 years, contributing to the projection that by the end of this decade 15 per cent of the population could have diabetes.

In the United Kingdom, six out of ten adults are now overweight, costing the NHS £4 billion annually. In England, one in eight hospital admissions is for chronic pulmonary obstructive disease (COPD). Only 51% of NHS patients with type 2 diabetes get the evidence-based care they need, and the latest government White Paper on public health suggests that the current model of general practice – despite its many strengths – has failed in many inner cities to tackle adequately inequalities in need.  As for the effectiveness of NHS commissioners in responding to chronic conditions, despite primary care trusts spending 25 per cent more on community services over the past two years, evidence from the Audit Commission shows that ‘efforts to control the demand for non-elective care have had no impact nationally’.

Given all that, Simon discussed five possible additional ‘game changers’ in respect of chronic disease, over and above conventional approaches to primary and secondary prevention. These were:

• Chronic disease payment reform: Simon reviewed the US economic evidence that organisational ‘integration’ in the form of hospital mergers and provider consolidation was in fact driving prices up. He described detailed techniques being used by US payers/commissioners to make transparent the quality and efficiency differences that exist between providers, to incentivise improvement, and also the spectrum of payment reform initiatives that are relevant to chronic conditions, including new primary care reimbursement models. Several of these could be adapted for the NHS tariff environment.
• Multispecialty clinical groups as a possible model: Simon identified a number of ‘real life’ US examples of doctor-led multidisciplinary medical teams who were not part of hospital groups, and which had successfully taken on delegated ‘commissioning’ budgets – and succeeded in effectively managing chronic conditions, so reducing avoidable hospital usage. In many respects these were closer parallels to the new NHS primary-care-led GP commissioning consortia than were hospital-based models such as Kaiser or Geisinger.
• Specialist commissioner models for chronic disease: About 100 million people in America get health care funded by the government (compared with 160 million who do so from their employer, and others who fund individually). In the case of Medicaid, most states contract the ‘commissioning’ responsibility to private-sector commissioners who act on their behalf. Similarly, in the tax-funded Medicare programme, individuals have a choice of commissioner and about 25 per cent of people have now chosen a privately managed ‘coordinated care’ plan rather than the traditional ‘fee-for-service’ Medicare programme. People with multiple chronic conditions also had the additional option of choosing to be in a ‘special needs plan’. Simon discussed the pros and cons of some of these models, their track records in improving care and utilisation patterns, their proposed funding changes over the next few years, and possible parallels for the NHS commissioning function.
• Deploying new technology at scale: Simon identified some of the new enabling technologies that could beneficially improve chronic conditions through:  new decision support tools for professionals and patients; new technologies to allow remote monitoring, telehealth and  new diagnostic and clinical interventions; workforce productivity enhancement; and as interactive technology platforms for ‘nudges’ to consumer behaviour.
• Consumer incentives and ‘nudges’: There is a spectrum of action needed from broad social changes through to support for individual healthy lifestyle choices. Simon reviewed some of the emerging science that integrates cognitive psychology and economics. He discussed its application to primary and secondary prevention of chronic conditions, and illustrated the approach with new models now being deployed by UnitedHealth for diabetes prevention and control, reducing tobacco usage, managing weight, healthy workplaces, and personal ‘rewards for health’ incentives.

In conclusion, Simon stressed that, while the challenge was substantial, the good news was that, to a great extent, improving health and chronic disease management is the ‘art of the possible’ – we now have effective models in the NHS and internationally, the challenge is to scale them. Failure to do so effectively will leave the NHS increasingly exposed – both in terms of the rising burden of avoidable ill health, and in terms of its impending ‘fiscal crunch’.

Discussion points

The wide-ranging discussion included such issues as:

• The role of whole population primary prevention versus more targeted secondary prevention
• What it will take to get governments to act, versus adopting a ‘Nero-like’ stance?
• Can we learn from countries like Brazil, where large numbers of primary-health workers have been trained up and sent out to ensure medication is followed and healthier lifestyles adopted?
• What is the role of social networking in influencing people, via peer groups, to change their behaviour, such as taking more exercise and eating more healthily?