Integration ahead

DH's recent evaluation of  the integrated care pilots has been found wanting in several quarters.  GP magazine put in a Freedom of Information Act request for clarity on DH's claim that this telecare route will offer £1.2 bn savings, but was turned down.  A lesss investigative approach from Nick Goodwin of the King's Fund echoes the less than enthusiastic response: "It is fair to say that the collective results of these pilots have been mixed."  He also observes that these pilots suffered from a common problem with integrated care, where the process of integration gets priority over the experience of care.  Another significant finding from the report was that emergency admissions increased over the period studied, while outpatient and elective admissions decreased.  The King's Fund is itself currently looking for case sites in its study of co-ordinated care for people with complex chronic illnesses.

Balancing act

A DH discussion paper on personal health budgets sets the scene for the programme, which will be rolled out from April 2014. Reflecting on the experience of the Netherlands, an article in the BMJ offers some wisdom based on having learned the hard way. At a recent conference, deputy head of NHS Commissioning Andrew Sanderson proffered the warning that personal health budgets did not provide "an open ended system of entitlement" and that there would need to be a robust way of managing demand. There's also a paper from the Association of Directors of Adult Social Services that looks at the position of young carers in the era of personalisation.

Steady as she goes

Tai chi retains its status as exercise regime of choice for a range of health conditions. A recent trial of a tailored Tai chi programme to improve postural stability with people with Parkinson's disease found benefit amongst mild to moderate Parkinson's sufferers. Research in Sports Medicine offers another review of this form of exercise for falls prevention. Elsewhere, Tai chi is described as a "promising intervention" for reducing fracture risk amongst older osteopenic women. Exercise of any kind is recommended for people with chronic illness and depressive symptoms in a systematic review.

Venn diagram

The overlap between long term conditions relating to physical health and mental health conditions is substantial. According to a report from the King's Fund and the Mental Health Foundation, over a third of people in England with a physical long term condition also have mental health problems; on the flipside, nearly half of people in England with a mental health problem also have a long term physical health condition. Either way, this amounts to something like 4.6 million people and between £8 billion and £13 billion per year in healthcare spending. The report argues that we could do better and that the main route to improvement is through integration. Doing nothing to address the emotional and mental health problems attendant on long term conditions risks the ability of people to manage their physical health. A study from the US looks at how to improve medical adherence amongst people in primary care with co-morbid long term physical and mental conditions (diabetes, coronary heart disease and depression). An analysis of results from the CO-MED trial focuses on depression treatment in patients with general medical conditions. A Cochrane systematic review of self monitoring of blood glucose for people with type 2 diabetes finds this has limited effect on glycaemic control in patients not using insulin. A study underway in Australia, Diabetes MILES, assesses the psychological aspects of living with diabetes: an early publication examines the methods and sample characteristics.

Quod erat demonstrandum

The waiting is up for the Whole System Demonstrator programme to report its findings and the headline is a careful yes to telecare: "if delivered properly, telehealth can substantially reduce mortality, reduce the need for admissions to hospital, lower the number of bed days spent in hospital and reduce the time spent in A&E." Started in 2008, this was the largest telecare RCT, covering 6191 patients and 238 GP practices in three areas (Kent, Newham and Cornwall) and covering three major long-term conditions, diabetes, heart failure and COPD . The figures look encouraging: in addition to reductions of 15% in A&E visits, 20% in emergency admissions and 14% in elective admissions, there's a 45% drop in mortality rates. However, this is only the top level data - the small print is yet to be released. The caveat of "if used properly" may constitute something of a warning: last month the King's Fund suggested that there's danger in the technology leading where the organisations cannot effectively follow without substantial change. DH has indicated that the yes is enough: its new campaign, "3 million lives," is aimed at "providing national leadership, strategic direction, and advice to NHS and social care organisations" in implementing telecare more widely. Again, the detail is to follow "in due course."

Modelling

Predictive risk models are used to predict such potentially avoidable and costly events as unplanned hospital admissions. They form a key element in wider strategies to address chronic illness. DH has made it clear that it does not intend to commission updates to the Patients at Risk of Re-hospitalisation tool (PARR++) or the Combined Predictive Model, so the Nuffield Trust has stepped into the breach and offers a guide to help commissioners choose appropriate models.

At arm's length

Ahead of the long-awaited reporting from the UK Whole System Demonstrator (WSD) telehealth projects, Audit Scotland provides a review of the issues and looks at programmes north of the border. There's some compelling evidence on the use of telehealth to avoid hospital admissions for people with COPD. The King's Fund has published the third in a series of papers on the experience of implementing telecare and telehealth across the 12 WSD Action Network sites, which takes a more cautious view of the options for implementing telecare nationally. According to the King's Fund, significant cultural and organisational barriers may present more of a challenge than the development of the technology. Meanwhile the Good Governance Institute takes a much more bullish approach, although, like the King's Fund report, does suggest that this will only work if accompanied by systemic change.

Nothing about me ...

... was well on the way to becoming reality as Andrew Lansley launched the Right Care shared decision making programme. Under the lovely mantra "Right Care, Right Patient, Right Place, Right Time," the thinking behind this policy is driven by the patient empowerment agenda that has run through the government's health reforms. The NHS Right Care site provides an update on the roll-out of the programme and the publication of Patient Decision Aids (hosted by NHS Direct). A team from Imperial College's School of Public Health asks whether shared decision making involving patients with chronic musculoskeletal pain and various healthcare professionals improve patient care.

Take care

There's a week for everything, and from 14th to 20th November it's National Self Care Week. This year's campaign is being run in partnership with the Self Care Forum.
Meanwhile, here's an update of recently published work on self management:
The crucial role of information in supporting self care is examined in a review of how self management is applied in conditions like heart disease and kidney disease. Another review looks at evidence for patient self-management and access to healthcare services for ethnic minority groups living with diabetes. The British Journal of Cardiac Nursing offers a descriptive study of self management behaviours amongst patients with heart failure in Scotland. A qualititative study of primary care practices in the north of England assesses how self management issues are handled in general practice consultations where computer based disease management templates are also used.

It's going to get personal

The government has announced that it will implement personal health budgets for people receiving continuing care by April 2014. While the small print states that this is subject to evaluations of the current pilot programmes, these are due to report in October 2012, so this announcement looks slightly like jumping the gun. The NHS Confederation, which has been considering the matter for some time, has issued a paper summarising the results of its research.

Breathless

Around one in four people are “likely to be diagnosed and receive medical attention for COPD during their lifetime” according to a recent Canadian study published in the Lancet, which compares lifetime risk for COPD with that for other chronic diseases. Another study published in BMC Public Health takes an international perspective on assessing impact of COPD in the working age population. While there’s general agreement that this condition presents a huge challenge to health services, there’s less agreement on approaches. With the recent publication of an outcomes strategy (for COPD and asthma) and quality standards, DH has taken a stand. Current spending is mapped by Dr Foster for Pulse, revealing the inevitable variations. HSJ reports on GP-commissioned clinics for COPD in Norfolk, designed to promote self-management and reduce hospital admissions. NHS Improvement summarises what has been learned from National Improvement Projects on managing COPD as a long term condition, again focusing on self-management and reducing admissions.