Concepts and Debates in Contemporary Healthcare Regarding Care Pathways in Chronic Illness - Essay Example

? ANALYSIS ON CONCEPTS AND DEBATES IN CONTEMPORARY HEALTHCARE REGARDING CARE PATHWAYS IN CHRONIC ILLNESS The main challenges that are faced globally in the 21st century will be the increasing burden of chronic diseases (WHO2002). Increased longevity, of lifestyles , with increasing exposure to many chronic disease risk factors, and the growing ability to intervene to keep people alive who previously would have died have combined to change the burden of diseases confronting health systems. The Chronic conditions are being defined by the World Health Organization (WHO) as requiring “ongoing management over a period of years or decades “ and covers a wide range of health problems that go beyond the conventional definition of chronic illness, such as heart disease, diabetes and asthma. It includes some communicable diseases, such as the human immunodeficiency virus and the acquired immunodeficiency syndrome (HIV/AIDS),that have been transformed by advances in medical science from rapidly progressive fatal conditions into controllable health problems, allowing those affected to live with them for many years. The domain also includes some mental disorders such as depression and schizophrenia, to defined disabilities and impairments not defined as diseases, such as blindness and musculoskeletal disorders (WHO 2002), and also to cancer which impacts the chronic health as a fact of comorbid implications. There are others who have different definitions for chronic illness (Bunker,2001), the common theme is that these conditions require a complex response over an extended time period that mainly involves coordinated inputs from a wide range of health professionals and access to essential medicines and monitoring systems. All of which need to be optimally embedded within a system that promotes patient empowerments. Unfortunately healthcare is largely built around an Acute- Episodic model of care that is ill-equipped to meet the requirements of those with chronic health problems. Chronic conditions frequently go untreated or are poorly controlled until more serious and acute complications of chronic disease arise. Though whenever the chronic conditions are recognized, there is often a large gap between evidence-based treatment guidelines and current practice. For example. It has been demonstrated that only approximately 45% of service users with diabetes who had accessed health care in the United States by the end of the 1990s had received the recommended care; this proportion was some what higher for patients with congestive heart failure, but , at 64% , still suboptimal. There has been a systematic review of quality health care in general practice in Australia, New Zealand and the United Kingdom found that, even in the best-performing practices only 49% of patients with diabetes had had been prescribed beta blockers after heart attack. On response to the emerging and difficult challenges put by chronic diseases, several countries have experimented with new models of healthcare delivery that can achieve better coordination of services across the continuum of care. Yet, the better coordination of care delivery has a logical aspect, the available evidence on the value of different approaches remains uncertain (Capewell,1999) Coupled to it is, the diversity of European healthcare systems means that there is unlikely to be a universal solution to the challenges posed by chronic disease. What may be possible in one healthcare system may be impossible, at least in the short term, in another form and philosophy of a similar system if the two differ in critical aspects. Hence each system must find its own solution, although it can also draw on the lessons learned by other and the evidence can be reflected while putting practice to care. Thus there is a need to explore potential implications for different stakeholders in chronic care so as to identify contextual, organizational, professional, funding and patient-related factors that enable or hinder implementation of strategies to address chronic conditions. Such an approach will be able to provide a platform for identifying best practices and the pre requisites for implementing them. The issue of public health in contemporary Britain is a misnomer. Britain is now healthier than ever before as the life expectancy has increased and some of the life threatening killer diseases has taken a retreat due to the public health and advances in treatment. But, at the same time the problem of health inequalities remain a issue in the amidst of the observation that the general health of the population is improving. This is due to the reason that the health of the least and the less well offs either improve very slowly than rest of the population or in some cases goes quite worst leading to the problem of health inequality. This issue is challenging for the physicians and the care givers. It also suggests the fact though the UKNHS policies and interventions really strive to reach each and every people but they also fail in some specific sections of the population. The Health Development has the task of developing the evidence base in health to inform policies and practice to reduce inequalities. The HAD has done reviews on issues like low birth weight, social supports in pregnancy, prevention of drug abuses, sexually transmitted diseases and HIV, physical activities , injury prevention. Management of obesity and lifestyle diseases but the Geriatric problems has been undermined in this issue.(Bunker,2001) The Challenges and the Advances in healthcare that keep people alive should be updated and viewed from cross sharing approaches of care specifically when designing care for the chronic patient population. Although not curing, these approaches have led to growing numbers of people surviving with chronic illness. At the same time, the proportion of older people in the population is also growing, further increasing the number of those with chronic health problems because of accumulated exposure to chronic disease risk factors over their span of lifetime and thus the burden of disease as chronic illness is always on the rise.. The consequences are not trivial. In 2006, 20% to over 40% of the population in the European Union aged 15 years and over reported a long standing health problem and one in four currently receives medical long-term treatment. There are also a growing number of people with multiple health problems and with co-morbid risk factors aggravating the condition of the chronic disease and imposing challenge to care. These are most common among older people, with an estimated two-thirds of those who have reached pensionable age are having at least two chronic conditions. The implications for health systems and society as a whole are formidable. People with chronic health problems are more likely to utilize healthcare, particularly when they have multiple problems. For example, in England, people with chronic illness account for 80% of general practice consultations and approximately 15% of people who have three or more problems account for nearly 30% of inpatient days.(Unal,2004) Chronic diseases place a huge and substantial economic burden on society. Estimates for the United States place the costs of Chronic illness at around three-quarters of the total national health expenditure (Capewell,1999). Some individual chronic diseases, such as diabetes, account for between 2 and 15% of national health expenditure in some European countries (Hildson,2004) (Mulvihill,2003) Chronic conditions have become vastly more complex to manage as new, more potent, but also often potentially more hazardous, drugs become available . However, these drugs are often being given to people whose characteristics, in particular their age, would have excluded them from the trials that demonstrated their effectiveness (Capewell,1999). It is not known whether evidence about many medications can be generalized to the types of patient that have been excluded from trials because of their age or health problems (Hildson,2004). Thus, the disparities between results reported in trials and those obtained in routine clinical practice mean that much of the reputed evidence base for clinical decisions is of limited value (Bunker,2001). A further complication is that many people with chronic illness will be receiving treatment for several conditions and will thus be consuming a complex combination of pharmaceutical preparations whose combined efficacy and scope for drug -drug interaction have never been adequately tested. In Europe, between 4 and 34% of people aged 65 years and older use five or more prescription medications The case study reflected how by following existing clinical practice guidelines, a hypothetical 79 year old woman with chronic obstructive pulmonary disease, type 2 diabetes, osteoporosis, hypertension and osteoarthritis would be prescribed 12 separate medications, a mixture that risks multiple adverse reactions among drugs and diseases. The consequences of a complex medication regimen can be illustrated by the case of a 76 year old woman with heart failure later she developed diabetes. She controlled her blood pressure with tablets which worsened her renal function. A statin lowered her cholesterol, but her liver function was severely compromised. Beta blockers made her breathing worse and her warfarin had to be stopped after a gastric bleed. The real ways seemed to be a new symptom or drug side effect to deal with the risk of adverse drug reactions increases with multiple (co) morbibidies, the use of some type of drug (e.g. warfarin) and the number of drugs taken .The use of multiple medications also increases the risk of inappropriate prescriptions among adults with two or more chronic conditions. The patient population review (from 16% in Germany to 32% in the United States ) reported a medical or medication error such as wrong dosage, wrong medication or erroneous laboratory tests upon which their treatment was made. Multiple medications may increase the risk of problems associated with ageing, such as cognitive impairment and falls, and increases in complexity of treatment. Complex medical and Drug regimens has been associated with substantially lower adherence, further impairing effective treatment (WHO 2003). While these factors highlight the challenges facing patient, health carers and health professionals alike in managing chronic health problems , multi morbidity impacting the further aspects of patient complexity, which also reflects determinants beyond biological factors that impact on health status and influence the effectiveness of specific treatments, such as socioeconomic, cultural and environmental factors and patient behaviour (WHO 2007). Therefore, while patient complexity can be challenging when addressing treatment goals for one condition, it will become ever more complex when attempting to prioritize treatment targets for multiple conditions. The goals of chronic care are not to cure but to enhance functional status, minimize distressing symptoms, prolong life through secondary prevention and enhance quality of life (Millward, 2003). It is clear that these goals are unlikely to be accomplished by means of the traditional approach to healthcare that focuses on individual diseases and is based on a relationship between an individual patient and a doctor. While it is equally clear that what is needed is a model of care that takes a patient centric approach by working in partnership with the patient and other healthcare personnel to optimize health outcomes, it is much more difficult to define any of the best model. Each approach is highly dependent on context, with terminology used in one setting having a quite different meaning in another one. Therefore, many organizational interventions, such as stroke units, are evaluated as black boxes, in which the intervention is defined by the name given to it, often with little understanding about the critical factors determining the success or failure. Chronic illness confronts patients with a spectrum of needs that requires them to alter their behavior and engage in activities that promote physical and psychological well- being to interact with health care providers and adhere to treatment regimens, to monitor their health status and make associated care decisions possible in reality, and to manage the impact of the illness on physical, psychological and social functioning (Millward,2003). There has been increasing responsibility taken by patients for self-management can create particular challenges for those with multiple conditions, as they may experience aggravation of one condition by treatment of another. For example, a patient with chronic respiratory disease may struggle to adhere to exercise programs designed for their diabetes (Unal,2004). Patients vary in their preferences for care and the importance they place on health outcomes. Thus, some will prioritize maintenance of functional independence over intense medical management while others will be willing to tolerate the inconvenience and risk of adverse effects associated with complex multiple medication regimens if this is linked to longer survival, even if at the expense of quality of life (Unal, 2004). The ability of patients to develop individualized treatment plans is, therefore, of critical importance for effective care. The growth of the consumer society, coupled with the explosion in information available one the internet, is creating more empowered patients, a phenomenon acting to increase the responsiveness with which health services are delivered. However, this may also compromise equitable access to care, as the digital divide enables those who are most privileged to take greatest advantage of the new opportunities provided while those in most need are left behind (Bunker,2001) . The situation is exacerbated as populations change, with increased global migration creating groups who, despite the goal of universal coverage, may fall between the cracks, especially if their migration has been illegal (Millward,2003). Unfortunately. our understanding of the scale and nature of any impact of these changes on access to care remains limited. The shifting Balance of care. Taken together, these developments can be seen as evidence of a growing complexity of healthcare. They are influencing profoundly the way the healthcare is being delivered. These influences can be considered under several headings (Capewell,1999) First, the growing opportunities for early intervention, coupled with a greater recognition in some countries of the benefits of reducing the burden of disease as a means of relieving pressure on health systems, is shifting the balance between treatment and prevention. In the United Kingdom, for example, a 2002 Treasury study on future needs for health care constructed a variety of scenarios differing largely in the extent to which the health of the population improves. The difference in costs in 2022 between the most optimistic and pessimistic scenarios was approximately 30 billion (50 billion), approximately half of the 2002 National Health Service (NHS) expenditure (Millward,2003). Yet the issue is not one of simply shifting resources from treatment to prevention; rather it is one of finding ways to integrate the two, with prevention strategies that take full advantage of developments in health care while reorienting health care to embed prevention at all stages. Second, there is a changing balance between hospitals having the advantage of confining the patient in one place, waiting for a series of investigations or a sequence of treatments to be undertaken. The patient is seen when it is convenient for the health care providers. Organizationally, this makes it easy to deliver complex packages of care, but it also brings major disadvantages for the patient, whose liberty is restricted. Even for those people requiring continuing care, hospitals may not be the most appropriate setting to receive and deliver it. Patients with advanced cancer may be better placed in a hospital; but those with moderate disabilities may be able to manage better in their own homes but with enhanced nursing or other support. Again, this introduces a degree of complexity, as the needs of the patient are assessed and alternative modes of care provided. Third, there is a changing balance in the degree of professional and patient involvement in care. In a less-deferential society, patients are less willing to accept instructions without formal explanations. At the same time, it is recognized that many chronic conditions where the course of the disease may be labile, such as asthma or diabetes require significant participation by informed patients (Capewell,1999). This in turn, calls for support from healthcare providers inform and enable patients to self manage their illness and may also necessitate an ongoing collaborative process between patients and professionals to optimize long term outcome. Fourth, as already noted, there is a changing balance between evidence and intuition in the clinical encounter, with a growing quest for evidence to under line the clinical practice, and for mechanisms to ensure that the evidence is acted upon, that performance is assessed and action taken to improve it. This balance is, however, dynamic as initial enthusiasms for protocol-driven care confront the reality of individual patient characteristics, thus exposing the limits of determinism (Unal,2004). Fifth, in the face of evidence of growing inequities in societies, there is the shifting balance between services that simply respond to demand and those that proactively seek need, even when it is not voiced as demand, in the knowledge that those whose needs are greatest may be least able to access the care that they need. Sixth, there is the growing potential of information technology. Patients accustomed to booking holidays or shopping on the Internet are increasingly puzzled by the continuing reliance on postal communication by health service. In theory, booking an appointment should be easy. Yet there is a crucial difference. The Internet model of a general holiday booking, involving the booking of asset of return tickets and a hotel, is analogous to a single episode of care, for example an attendance for a routine medical examination. However, the traveler in search of a tailor –made holiday, visiting a sequence of destinations suited to his or her individual needs, and using a variety of travel modes (a model more analogous to a patient with a multiple chronic diseases ), will require the services of travel agent. Thus given that the most patient journeys more closely resemble the actual holiday market, it is unsurprising that health care information systems often struggle to deliver what they promise. Finally, there is the challenge of developing a work force to respond to the changing health care environment. This is a vast area, drawing together many of the previous six issues but added to by the problem of how to provide training in the increasingly diverse settings for health care. In brief, there should be a approach comprising of interacting system components considered key to providing good care for chronic illness; self-management support, delivery system design, decision support and clinical information systems. These should be set in a health system context that links an appropriately organized delivery system with complementary community resources and policies. References Bunker, J. (2001). Medicine matters after all: measuring the benefits of medical care, a healthy lifestyle, and a just social environment. London: Stationery Office/Nuffield Trust. Capewell, S., Morrison, C. E. and McMurray, J. J. (1999). Contribution of modern cardiovascular treatment and risk factor changes to the decline in coronary heart disease mortality in Scotland between 1975 and 1994. Heart81: 380-6. Hillsdon, M., Foster, C., Naidoo, B. and Crombie, H. (2004) The effectiveness of public health interventions for increasing physical activity among adults: a review of reviews. London: Health Development Agency. Millward, L. M., Kelly, M. P. and Nutbeam, D. (2003). Public health interventions research: the evidence. London: Health Development Mulvihill, C. and Quigley, R. (2003). The management of obesity and overweight: an analysis of reviews of diet, physical activity and behavioural approaches. London: Health Development Agency. Unal, B., Critchley, J. A. and Capewell, S. (2004). Explaining the decline in coronary heart disease mortality in England and Wales between 1981 and 2000. Circulation109 ; :1101-7. Read More