Personal Health Budgets: good beginnings in the UK

Two-thirds of hospital emergencies correspond to chronic patients’ decompensation which is why the health care system has a vested interest in helping people with chronic diseases to take care of themselves and learn to decrease their attendance to hospitals. Knowing that this can not be prescribed, the English have developed a system of budgetary self-accountability.

In 2009, the National Health Service launched a Personal Health Budget (PHB) Pilot Program in 70 localities and after an evaluation, it has been extended to the entire population, according to the following principles: People who need long term health and social care agree with their local professional teams (social services, primary care and NHS administrators) the arrangement of an amount of money that should allow them to reach the objectives of the individualized therapeutic plans previously agreed.

The PHB’s intention is that people with multi-pathologies or with degenerative or disabling diseases, have their service buying options nearby such as social services, psychological or physical therapy support. However, primary care services, pharmacies and hospitals are excluded. The first assessments offered by Nuffield Trust are positive in terms, particularly, of life quality. The economic aspects of the evaluation are more controversial as it is very difficult to quickly collect the savings of inappropriate hospital services that have been reduced thanks to PHB.

Last century belonged to the doctor, this one should belong to the patient

RT @gesclinvarela Historia oral de la Práctica Basada en la Evidencia #PBE http://t.co/jXEyQ4o3o8

— X.M. Meijome (@EnferEvidente) julio 6, 2014 

This twitter account, @enferevidente, specializing in clinical safety, has offered us the link to a paper on the history of the EBM which is a jewel in itself. If you click on the tweet, you may access a collaboratively edited video from the British Medical Journal and The JAMA Network. It’s a chat, moderated by Richard Smith, where Gordon Guyatt, Kay Dickersin, Drummond Rennie, Brian Haynes and Paul Glasziou – all ‘parents’ of EBM. There are also connections with David Sakkett, Iain Chalmers and Muir Gray. If you wish to press the play button (do it through the link in the tweet), you will see how veteran scientists explain their conversion to the, new (at that time) way of seeing clinical research, along with their views on the current circumstances.

The future of EBM from its "parents"

What interested me most, however, was the last round of the chat, when Richard Smith questions the guests about how they see the future of EBM and clinical practice, and on this I made some notes as follows:

Patient-Centered Coordination (PCC): case report

In a hospital a fragile geriatric patient dies with multiple cronic diseases

Antonio dies at the age of 88 during one of his many hospital admissions and the primary care team closes the case with the following diagnosis: a) Parkinson 7 years of evolution, b) Heart failure due to valvular dilated cardiomyopathy, c) high blood pressure, d) cardiac arterial arrhythmia by fibrillation that required pacesetter e) depressive-anxious syndrome, f) frequent urinary tract infections, and e) progressive protein-calorie malnutrition leading to death.

The daughter needed her father’s small amount of  money therefore she didn’t want to send him to a residence for the elderly.

In the two years preceding the death, Antonio showed an absolute dependence in activities of daily life with a Barthel zero. He lived with a divorced daughter who had no income, and with his two grandchildren, her children. The dependency aid (destined for the caregiver not for the professional) and Antonio’s small pension were the biggest family’s sources of income so this was always an impediment on the proposed admission to a nursing home; although it was clear that the daughter, even with little support from the municipal home help, could not meet the needs for long term attention in the period towards of Antonio’s end of life.

In the last 3 years of life, this patient had consumed more than 100,000 Euros in services, with an impressive degree of incoordination.

In  Antonio’s case history for the three years prior to the hospital admission when he died, the primary care team counted 24 attendances to the emergency room of the hospital, for very different reasons, many of them linked to heart disease, but also due to falls, fever, depression, pain in the penis, etc. Of these visits, 15 did not result in hospitalization, but, instead, almost all required attention in the short stay unit or follow-up day hospital or an outpatient clinic. Nine hospitalizations (three per year) were made in Cardiology, Internal Medicine and Geriatrics, with a total of 77 stays. Nine interventions of social work at the hospital were also counted. The activity that Antonio has generated in the primary health care and at the municipal social services has not been recorded, but there’s no doubt that it was also plentiful.

Men (of my generation) don’t cry

By Joan Escarrabill

Emotional training has changed over time. A part of the men of my generation were taught to contain their emotions. Men don’t cry. Publicly expressing certain emotions can be considered rude (or, worse, a weakness). Privacy (i.e. solitude) is the only space suitable for male emotions. The intimacy understood as a personal space that is never shared. Privacy is a right and, above all, a way of working. There are some things can only be the product of personal reflection, in the strictest privacy.

I know I simplify things. Maybe we should not talk about emotions and intimacy. Maybe we should talk about "privacy". But now there are a couple of phenomena related to digitizations that, at the very least, are at on the verge of privacy: the collective intelligence and transparency.

Collective intelligence challenges the individual reflection as a basic tool for understanding. Adding up is so powerful! Adding up from different perspectives gives unprecedented solutions to complex problems. But I will focus on transparency.

Facebook generation or my generation understand transparency differently. The generation of men who don’t cry understand transparency from a simple perspective "we must always tell the truth, but we don’t have to always tell it all" and the question is, "Can so much transparency become toxic?"

Knowledge chain sanitation, a difficult undertaking

By Cristina Roure 

In one of my posts  from "Pantone" series, August 17, I was talking of the need for crystal clear knowledge sources so we can make appropriate decisions, but the point is that our sources are contaminated by a number of biases that permeate the decisions we make as citizens, as patients, as health professionals or managers, and this leads to over diagnosis and overtreatment. Faced with these biases, Gerd Gigerenzer and Muir Gray, in the book "Better Doctors, Better Patients, Better Decisions" propose some sanitization measures, to which I have allowed myself to add some homemade ones:

1. How to make research more relevant to patients

a) Regulatory agencies, such as the FDA or the EMA, should require studies demonstrating the superiority of the new drugs compared to the best treatments available, not placebo.
b) Independent sponsors should promote research on simple, beneficial and patient relevant treatments and practices that do not involve the use of drugs or technology, practices that for this reason lack sponsorship (exercise, healthy diets or checklists to improve clinical safety).
c) I would add that the so called Patient Reported Outcomes should be included in clinical trials, which unlike conventionally employed variables, report on the effectiveness of treatment perceived by the patient.

Hospital general vs factory hospital

In the post October 5, I explained how, according to the report "Future Hospital Commission" (Royal College of Physicians 2013), it would be ideal that, as soon as possible, the organizational models of the hospitals would be able to evolve in two directions: a) about one third of the health care activities should apply techniques of industrial quality, and b) the other two thirds of patients admitted (complex case-mix) should be treated radically differently from how it is done now, given the shortcomings of the work organization in the hospital wards.

In the current model, each admitted patient has a medical service and a medical specialist assigned. The clinical activity of this medic develops primarily through the clinical course of medical orders (including requests for evidence and pharmaceutical prescriptions) and through interdepartmental advice from colleagues from other specialties. As for the nursing work , there are several intensity models ranging from a major involvement in the clinical process to a trivial change of shifts.

Summary of the limitations of the current model of care for inpatients and the arising risk situations:

1. The allocation of a medical specialist doesn’t guarantee at all the care continuity because many of these specialists also have their other technical functions, specific to their speciality that are often more attractive that visiting the wards.
2. The guards’ medical model does not guarantee the maintenance of a homogenous quality of care, nor at night, nor on holidays.
3. The interdepartmental work, generally means little involvement. Specialists try to fulfil the commitment with an opinion and, rarely, joint clinical work derives from this activity.
4. In many hospitals, nurses have a working commitment to the continuity of care quality for admitted patients but this is not universal, and great variations between centres are detected.
5. Inpatients often undergo changes of bed, or even ward changes for reasons of centre’s logistics organization, and this fact is known to subject the patient to avoidable risks.
6. The quality of transfers of complex patients from the hospital to their homes is not guaranteed in all places and at all times.

Factory Hospital vs General Hospital

The report "Future Hospital Commission" (Royal College of Physicians 2013) proposes organizing hospitals into two distinct divisions. According to the described model, patients would enter two alternatives doors that lead to almost opposite paths: a) there would be a specific route for standard processes (lower part of the graph), such as: laparoscopic procedures, hemodynamic, scheduled surgeries, stroke codes, heart attack codes, etc, and b) the other route would be for patients admitted through the emergency room (except the codes) or suffering complexities that require general assistance, with the occasional support of specialists (the trajectory above the graph).

This proposal seems not only timely, but also hospital models nowadays are or should be largely along this line. But the publishing of an article in Health Affairs, signed by a team from the service of Cardiac Surgery at Mayo Clinic, has led me to consider that we should advance more in the methodology inherent to each of the two paths. This referenced work is titled: "From "Solution Shop" Model to "Focused Factory" in hospital surgery. Increasing care value and predictability", or the equivalent of a study of the evolution from store solutions where every client is different and requires a tailored response towards the targeted factory that uses the methodology of an industrial process. And this is where the Mayo Clinic are pushing the  accelerator: if we are able to indicate certain clinical procedures for well-defined types of patients –they say– we ought to know how to prepare to act with criteria of maximum efficiency and effectiveness.