Making the Connections: Developing Best Practice into Common Practice: page 4

Making the Connections: Developing Best Practice into Common Practice

Chapter 3 Meeting Specific Needs:

Chronic Disease Management:

Frustrations and Irritations

Need to extend role of GPs in pre-referral investigation; patients receiving secondary care and primary care at the same time with no co-ordination; inefficient and delayed communication from secondary care on (patient) discharge, including medication and follow-up; too many GP appointments used by patients for repeat prescriptions - need to review the role of community pharmacists; need to be innovative on public health message; need payment system for all independent contractors with the emphasis on health; need to invest in the future.

As demonstrated earlier, chronic disease is one of the major issues facing primary
care in the 21st century. One of the strengths of primary care is its ability to provide
a generic and holistic approach to care. This is particularly important in the management of chronic diseases as patients frequently present with multiple pathologies. A multifaceted approach to care is essential.

Effective Service Delivery

The key elements of effective chronic disease management comprise:

Prevention	Motivating individuals to think about and change their lifestyles - particularly in relation to diet, exercise and other health behaviours through public health interventions;
Information	For the public - which is easily accessible, understandable and up to date;
Partnership working	With patients - motivating and supporting individuals to take responsibility for managing aspects of their condition - lifestyle changes and concordance to drug protocols, etc.; With team members - health and social care systems, including treatment, joint training and development;
Clinical standards	Developing care pathways and protocols, with a holistic approach to care;
Assessment of clinical performance	Robust information systems, audit, appraisal, accreditation systems;
Support and development	Education and training (with protected time), organisational development.

Process of Care

The key elements of the process of care comprise:

Initial assessment

Diagnosis - criteria and confirmation

Options for management/treatment

Patient information/education

Follow-up and monitoring

Indicators for onward referral

The increasing incidence and range of chronic illnesses (including CHD, diabetes, asthma, epilepsy, mental illness, dental caries, etc.) is placing significant pressure upon the capacity of primary care to achieve models of "Best Practice" - such as the Scottish Diabetes Framework, the Clinical Standards Board for Scotland standards for the care of patients with schizophrenia and coronary heart disease and the CHD Taskforce Framework.

Primary care is the right place to focus the management of chronic disease, with referral on to specialist services only when appropriate and needed. But that requires staff with the right skills and support in primary care, thus seeking to reduce the demand on secondary care. This in turn requires secondary care to support the development of the capacity in primary care. NHS Boards need to ensure that local redesign programmes include both primary and secondary care perspectives.

A Partnership Approach to Care

The extent to which individuals are willing to take personal responsibility for their health may have a significant impact on health outcomes. A high percentage of chronic diseases are attributable to lifestyle (Davis et al, 1999). Prevention is therefore a major challenge for service providers and the public, and pharmacological developments may increasingly be focused on the treatment of risk rather than disease (in the way that statins have developed in recent years for treatment of risk in CHD).

The key to effective management is understanding the different trends in the illness patterns and their pace. A partnership between patients, clinicians and, where appropriate, carers is essential because:

in developing good practice, patients should be partners in their own care;
health care can be delivered more effectively and efficiently if patients are full partners in the process;
carers require support both in adapting to their new role and also in understanding the patient's illness.

Collaboration between LHCCs and the acute sector will be necessary in developing disease management tools, jointly managing both the change in referrals and follow-up clinics, the information flow necessary for performance management, the expectations of patients and the public and the support required from secondary care to an expanded primary care capability and capacity. It will be necessary to develop liaison, planning and organisational development support at a variety of levels within the respective organisations.

Models of Care

In order to meet the differing clinical needs and individual circumstances of patients
a range of models of care have been developed.

Self management - self-management programmes can be designed to reduce the severity of symptoms and improve confidence, resourcefulness and self-efficacy. Education and training that addresses continuous use of medication, behaviour change, pain control, coping with emotional reactions and learning to interpret changes in the disease and its consequences enables patients to become key decision-makers in the treatment process. An important element is learning from others; supporting growth in confidence and the ability to cope with the disease
(The Expert Patient DoH, 2001).
Group/community fora - an extension of self management, where groups of patients and appropriate members of the primary care team meet. This experience can increase the quality of life; it demonstrates much lower decline in activities of daily living, reducing dependency on health services by accessing community and voluntary organisations able to meet the needs of individuals.
Remote clinical management - for patients requiring greater support than provided
in the models above. NHS 24 will provide an opportunity for people to talk directly
to highly qualified and experienced nurse advisors, complementing the local health systems. The continuing development of telemedicine will provide particular benefits for individuals living in remote and rural areas.
Direct Clinical Management - locally provided diagnosis, prognosis and treatment options.
Managed Clinical Networks - the expertise available in all sectors working across traditional boundaries in primary, secondary, tertiary care and sectors outwith NHSScotland, ensuring a co-ordinated approach to care.
Shared Care - co-ordinated care provided by primary care and secondary care. The balance of care provided by primary and secondary care is dependant on the patient's clinical needs.

There are many examples of good practice across Scotland in the management of chronic diseases within primary care, with high quality structured care in which:

local needs are identified at micro (patient) level and macro (LHCC) level - identifying patients "at risk" and informing public health planning;
patients perceive they are involved in decisions regarding their care;
there is an improved quality of life for patients; ensuring chronic illness is appropriately treated and monitored;
there is accessible information, readily available in a range of public places including libraries, community schools, GP surgeries, pharmacies, social work and housing offices;

national standards are delivered with:
- practices having working protocols for assessment, diagnosis, treatment and onward referral
- comprehensive, easily accessible patient records
- development of registers and review/recall systems
integration of service delivery within primary care and between primary care and secondary care and other agencies, ensures continuity of care and teamwork;
there is ready access to training and availability of equipment for specific GPs and other members of the primary care sector with a special interest in chronic disease management;
performance management systems are in place to support clinical governance, providing opportunities for continuous learning and development.

Developing Best Practice into Common Practice:

Dumfries and Galloway CHD: The Coronary Heart Disease Task Force has developed a Managed Clinical Network, providing care pathways for all health professionals identifying what is required at each stage of a patient's care, ensuring a uniform approach across the region. The project is developing a patient-held record for cardiac disease - designed to facilitate continuity of care between primary care and secondary care and increase patient involvement in their own care.

The PCMG recommends that, to ensure high quality care and effective utilisation of the skills of the full range of staff (GPs, nurses, pharmacists, PAMs, etc.) there should be:

a locally supported, systematic approach at LHCC level to:
identifying local needs
agreeing the contribution which each profession can make towards meeting those needs
monitoring and review of the outcome of services delivered
using the nationally agreed standards and guidelines to agree the structure, process and organisation of care
ensuring appropriate training, development, support and supervision to safely deliver services
a process for involving primary and secondary care professionals in designing services which are resourced to have an increasing focus within primary care.

Meeting Specific Needs:

Managing Mild to Moderate Mental Health Problems in Primary Care

Frustrations and Irritations

Need to develop inter-agency referral systems; need to integrate service delivery bringing local agencies together; need to extend the community service beyond 9-5.

Mental Health is one of the three clinical priorities for NHSScotland. The majority of mental health problems are treated in primary care, and indeed constitute one of the most frequent reasons for visits to GPs - 300 consultations for mental health problems for every 1,000 people in a general practice during a year. (CMR July 2001)

Developments to Date

Despite the impetus of the Framework for Mental Health Services in Scotland (1997), the work of Scottish Health Advisory Service and the Mental Welfare Commission, the development of clinical standards for patients with schizophrenia (CSBS 2000) and other initiatives to improve the care of individuals living in the community with mental health problems, there is still significant variation in service provision across Scotland. To date many community developments have been particularly targeted at those with severe and enduring mental health problems. A parallel agenda is now required in primary care to address the needs of individuals with mild to moderate mental health problems. There is a need to build on good practice in evidence in some parts of the country with developments including practice attachment of mental health workers, dedicated primary and mental health care teams and CPN services targeted at the primary care mental health population. In addition, a number of developments have set out to build clearer links between primary care and social care services including the voluntary sector employment and volunteering services.

Deficiencies and impediments to effective service delivery in some areas requiring to be addressed include:

people having better access to information to help support self-management of their illness or how to access available services;
tackling the continuing stigma of mental illness among sections of the public;
better co-ordination between primary care teams, mental health teams and specialist services;
better integration and co-ordination of health, local authority and voluntary sector services;
improving the consistency in the services provided;
better support and training for primary care teams in diagnosis and treatment of mental health problems.

Effective Service Delivery

Our National Health explicitly acknowledged "poor mental health can come at any time and affect anyone". People want effective mental health services that make a difference by improving the speed, responsiveness and quality of care. Severe and enduring mental illness is only the tip of the iceberg. Anxiety and depression contribute to much wider community health problems which need the support of extended mental health services in primary care settings.

The outcome of less severe mental health problems could be improved if recognised and dealt with by a multi-faceted approach at an earlier stage. Evidence suggests (Mental Health Reference Group, 2001) a correlation between higher incidence of mental illness and social exclusion - e.g. poor housing and low employment opportunities leading to a lack of motivation and self-worth. Addressing issues leading to social exclusion may prevent recent onset mild and moderate depression becoming chronic. Interventions include a range of psychological and pharmaceutical treatments and patients with chaotic lifestyles require support with compliance.

The main focus in primary care is on individuals with mild to moderate mental health problems, and they can experience particular difficulties in gaining access to services and then in receiving a consistent standard of service. There is further work to be done to consider the implications for the roles and functions of primary care workers in enabling and supporting self help and self management among individuals and patient groups.

The provision of services needs to be designed locally to:

Encourage and support lifestyle changes.
Give information and support to patients, carers and communities.
Promote a change of public attitudes regarding mental illness.
Improve the quality and consistency of services provided to patients and carers.
Ensure that integrated services are provided within primary care and between primary care and secondary care.

The characteristics of high quality community-based mental health services include: (Framework for Mental Health Services in Scotland; Mental Health Reference Group.)

Development of multi-disciplinary and multi-agency teams - services provided by NHS and local authorities, voluntary organisations and self help groups.
Review of continuing appropriateness of treatment - pharmaceutical and psychological.
Multi-disciplinary/multi-agency care planning for patients with chronic mental illness (modelled on Care Programme Approach and CSBS standards for schizophrenia).
Regular training programmes on "frequently met issues" for members of the primary care team.
Managing crisis in the community, hence avoiding hospital admissions.
Reduction in waiting times for psychological and psychiatric services.
NHS Boards and Local Authorities supporting "accredited" voluntary organisations within their area.

Developing Best Practice into Common Practice:

Greater Glasgow: Having identified that less severe, common mental illnesses form the single biggest reason for patients presenting to the primary care team, the PCT and Health Board have developed a framework for the development of primary care mental health services, provided by a range of agencies and co-ordinated through LHCCs.

The PCMG recommends that:

NHS Boards, together with LHCCs and other local providers of mental health services, should develop proposals to utilise the specific resources available to promote mental health and wellbeing
PCTs should support LHCCs in developing processes and structures to deliver national and local standards in mental health in primary care
to support integrated care, PCTs should strengthen the relationship between primary care services and specialist mental health services, with Community Mental Health Teams clearly focused at LHCC/locality level
in order to improve access to a full range of services, NHS Boards should support LHCC participation in the development of multi-agency, high quality, locally-based mental health services.

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