The BGS Study Day, held in July in Basingstoke, included two presentations by Dr Gill Turner and Dr David Black on chronic disease management.

Both talks emphasised the strategic context to Chronic Disease Management and the importance set on it in the NHS Improvement Plan published in June of this year. The Royal College of Physicians, together with the Royal College of General Practitioners and the NHS Alliance, recently published a joint report entitled “Clinicians, Services and Commissioning in Chronic Disease Management in the NHS”. The background to this is a growing belief that the future of health care lies in the effective management of long-term conditions, and this can only be achieved with models of service provision championed by clinicians in partnership with patients. The document is an attempt to put clinicians back at the heart of the commissioning process because the evidence is that effective service re-design will not occur without their enthusiasm and active leadership.

Models for chronic disease management
Dr Black’s talk gave examples of Chronic Disease Management (C.D.M.) in other medical specialties and updated the group about the current thinking in elderly care, particularly with the Evercare model and the Kaiser Permanente processes. The important point for geriatricians is the ability to build greater trust across primary and secondary care. This is not an easy cultural change. To move C.D.M. forward, it is proposed that joint clinical directorates are set up across primary and secondary care to manage specific chronic disease programmes. These clinical directorates would be multiprofessional and start with a clinical governance approach, sharing information, discussing incidents, complaints and using NSF’s for debate around service change.

Dr Turner provided an insight into how this might really work at locality level with locality teams, facilitated by the single assessment process.

Using the population stratification in chronic disease management model (see figure 1 below), Dr Turner argued that geriatricians and geriatric services should not just be concentrating on the level 3 case management approach to the most frail (the Evercare approach) but can make just as much, if not greater impact, by concentrating on level 2 which is an early frailty based approach. She stated that there is now excellent evidence that if you appropriately intervene at the time of early stages of frailty, there will be marked improvement in morbidity, mortality and considerable cost savings. This is based on reducing functional decline through the process of comprehensive geriatric assessment as a multidisciplinary intervention. One limiting factor to this approach is that we still do not have a validated national screening tool to identify those that need intervention.

Working with PCTs
Finally she discussed how this would work in general practice and indeed how the new general medical services contract for GP’s might lead to new models of care. It is not yet clear how these specialist services will be commissioned and paid for. Possibly as locally enhanced services; possibly secondary care will vertically integrate into the community; possibly many more salaried GP’s or GP’s with a special interest will be involved; or perhaps a completely new type of specialist working in the community may be developed.

Most of the group discussion was on how to work effectively with PCT’s. There is currently wide variation of experience from those where the PCT’s are now actively involved with the geriatric departments, building locality based teams and commissioning community services from established departments, to those where they are not engaging at all with the geriatric department. The single message from the day appears to be, if you have an opportunity to work with your PCT, in any forum, whether a new clinical directorate or not, grab it!

David Black