Contemporary Approaches to Managing Long Term Conditions/Chronic Disease - Essay Example

Introduction With over 60% of adults in the United Kingdom reporting a Chronic Health problem, including diabetes, mental health, obesity and others (Department of Health, 2004), it is evident that the management of long term chronic conditions is an important and challenging aspect of providing healthcare. Chronic conditions are, by their nature, those which cannot be ‘cured’ in the more typical sense, so treatment generally involves long-term involvement by healthcare providers and the provider must aim to best control the condition with the aim to improve quality of life for the sufferer (Department of Health, 2004). The situation becomes more complex when considering the aging population of the UK. Over 70% of people over the age of 60 will have more than one chronic condition (Department of Health, 2004), making management more complex and limiting treatment options. Managing chronic conditions requires the provision of a multitude of services beyond traditional medications, including but not limited to hospice care, home-visit nursing staff, occupational therapy, recommendation of non-traditional medicines and services, and a holistic approach to providing care (Morton et al, 2005). The provision of these services is costly to the NHS and thus there is a significant need for the different divisions to be managed properly and carefully. The purpose of this essay is to analyse the different approaches to caring for those with long term, chronic conditions by looking at the shift from a ‘reactive’ model of care to an ‘anticipatory’ model of care and the benefits of this change. The essay will consider the different elements involved in providing stable and effective long-term care to an increasing number of UK adults with these conditions, as well as analysing the successes and failures of the contemporary models, including the increasingly important holistic care model. By analysing these management measures, it is hoped that a socio-political context for the approaches will emerge and the consequences for the public health model will be apparent. Reactive Healthcare Delivery Reactive healthcare delivery essentially describes a system which relies on treating a ‘perceived departure from health’ (Evans et al, 1994, p29). It is treating the absence of health once it has been made apparent, treating something which already exists. It has been widely noted by the literature that the current healthcare system, both in the UK and further afield, generally rely on this system. It has been noted that the major problem with using such a model for managing chronic diseases is that it is a negative model, with the absence of ill-health being used as a model for health (Evans et al, 1994). It has been assessed by the Department of Health (2004) that this model of providing health care is based upon a 19th century model, which is aimed at the acute health issues which posed more of a risk at the time; viruses, bacterial infections and other acute illnesses developing as a result of a short-term threat or obvious trauma. Whilst these are still important issues in healthcare management, the aforementioned figures suggest that the majority of the UK adult population are suffering from chronic illnesses (rather than acute), and so this model may need to be addressed. There are, of course, benefits to the reactive healthcare delivery system. Economically, the NHS may benefit from using reactive models of care as it will have less of an involvement before the healthcare issue; less money needs to be spent prior to the development of the chronic disease (Cheah, 1997). Whilst this may seem true on the surface, it may be better economically to spend money on anticipatory healthcare to prevent life-long medicine prescription. It has been suggested by the Department of Health (2004) that 8 out of the 11 leading causes of hospitalization are due to causes that could lead to a fall in admissions if anticipatory care was used more strongly throughout the NHS system. The anticipatory model of care has also been shown to be effective in those patients who mainly rely on self-care; again it seems more economically stable to treat patients using GP or other outpatient services when complications arise (Landon et al, 2007). Self-care is an important issue in chronic disease management, although it has been suggested that education on such matters could be more effective. Taking all these elements into account, it would seem that there are some short-term benefits to reactive healthcare delivery but a move to anticipatory care may be beneficial and should be investigated and instigated in a wider range of areas. Anticipatory Healthcare Delivery Anticipatory healthcare delivery seems to be the new direction which healthcare management is heading (Landon et al, 2007), and for good reason. Whilst anticipatory healthcare may seem to some to be overly cautious and unnecessary, it has been suggested that the NHS could save huge amounts economically with a small investment in anticipatory healthcare (Department of Health, 2004). NHS Health Scotland (2011) has published a huge amount of information about the upcoming push towards the new anticipatory healthcare delivery model, but essentially describes it as a movement to tackle healthcare inequalities throughout the region, building in primary healthcare services to provide better preventative care and providing early interventions. One aspect of NHS Health Scotland (2011) is to improve the services within the region to ensure faster access to services. As previously mentioned, the NHS is based around a 19th century model of care which benefits those suffering from acute conditions. One of the major problems with the anticipatory model of healthcare is that it requires changes in almost all areas of the NHS, and may include increased training for staff, advertising and advice provisions, and extension of outpatient services (Bell & Troxel, 1997). These are perhaps amongst the main reasons why the anticipatory, preventative model is not fully implemented, but should not be seen as an impenetrable barrier to full use of the system (Proudlove et al, 2006). Another issue with a full remodelling is changing the definition of health from the absence of disease to a more holistic view of well-being (Lorig et al, 1999), which can be a challenge as ‘disease’ tends to be seen as imminently treatable, whilst general ill-health can be ambiguous and difficult to treat. Holistic Approaches to Managing Chronic Disease Holistic approaches are another element of managing long term chronic illnesses. Holistic care involves inclusion of well-being for the patient (and thus leans more towards the broader, contemporary definition of health mentioned above) and inclusion of various family members and carers (Morton et al, 2005). It also involves an approach that may move beyond the realms of traditional curative medicines, and thus is relevant in any discussion regarding the anticipatory healthcare delivery system. It has been shown that self-care is important in chronic disease management (Lorig et al, 1999), and thus involvement of various family members and carers could play a vital role in a new, contemporary system that aims to prevent the escalation of these chronic diseases. Family members may be able to provide care beyond self-care, without significant involvement from the NHS and thus is economically and politically viable. It is also evidently socially viable, as care for a family member is implicit within Western culture. As it is, the NHS does target involvement from family members in several areas, with healthcare information actively targeting those wishing for more information about the health of loved ones. However, it may be beneficial to improve the system to actively encourage loved ones and relatives to become part of a preventative holistic approach. It has also been suggested that support networks are important in ensuring patient compliance. Kyngäs & Rissanen (2001) found that adolescents with family support were far more likely to comply with their medication needs and follow instructions for their care, partly because they were encouraged to follow medical protocol by these networks. As chronic disease care can involve several medications which need to be taken on a long-term basis (Cheah, 2001), patient compliance can sometimes be an issue (Morton et al, 2005). Any improvement in patient compliance is therefore important in dealing with the increasing number of chronic disease patients, and therefore this holistic approach needs to be used carefully and be considered across the healthcare providers. Holistic approaches also require caring for the psychological elements of chronic illness care. Gore et al (2000) suggest that, for chronic obstructive pulmonary disease (COPD) at least, these holistic approaches can be hugely beneficial to the patient. As healthcare begins to recognize more mental health issues and secondary issues (Morton et al, 2005), it seems appropriate that chronic disease patients benefit from this new information. The Contemporary Shift from Reactive to Anticipatory Models of Care As previously mentioned, reactive models of care are less efficient than anticipatory models of care in the context of chronic disease. In the case of diabetes, for example, a lot of the damage from the disease has occurred by the time of diagnosis (Wagner et al, 2001), meaning that care is often targeted at combating the symptoms rather than the cause of the disease. Continuing to use diabetes as an example, an anticipatory model of care would combat the causes of diabetes, such as high sugar intake and obesity (Wagner et al, 2001), to help prevent the associated complications. As diabetes becomes one of the most prevalent chronic diseases in the UK, it is evident that this would benefit a huge number of sufferers and could potentially help to prevent the disease and save healthcare services huge amounts of money. This is not just true of diabetes, but can be applied to many other chronic diseases. An interesting area of development is concerning genetic diseases. There are a number of screening programs already in place for prospective parents, both on these individuals and the foetus (Marks et al, 2002). Genetic testing can help parents make informed decisions about chronic diseases such as spina bifida, Down’s syndrome, cystic fibrosis and more (Carey, 1992). Whilst these screening programs may be expensive to implement, the technology is available and should be used. The screening could potentially save the NHS thousands of pounds in care costs (Marks et al, 2002), as well as preventing the mental health issues that can be associated with being a long-term carer (Green & Britain, 2004). This can also be considered as a part of the holistic model of care outlined above, as preparation for the possibility of a genetic disease may help friends and family members, as well as the concerned individual if applicable. There are other elements to preventative care. It is currently recommended that patients with HIV are given preventative psycho-social care (Scofield, 1995). This is a merge of holistic and anticipatory care, in that it aims to incorporate elements beyond the purely medical (immune system boosting drugs, for example) and involve family members, and it aims to help prevent the spread of HIV and AIDS to the wider community by providing education. This is an interesting concept, but perhaps should be applied to other areas of medical practise with caution because HIV is in a rare category of infectious chronic diseases. However, providing psycho-social care is an appropriate use of resources in many cases. For example, those dealing with a disease such as Huntington’s or Alzheimer’s may be functioning until the end-stages of the disease (Green & Britain, 2004), which means that they may require psycho-social care before needing medical intervention for the symptoms. They may require counselling to deal with the approaching effects of the disease. This will help the sufferer to be more aware of their situation and could be a part of palliative care. As previously mentioned, NHS Health Scotland (2011) has one of the most accessible and inclusive models of anticipatory care, most of which involves aspects of holistic care. One of the main aims of the directive is ‘providing early interventions to prevent escalation of health care needs’, encompassing the approach of anticipatory healthcare to improve identification of disease and improve knowledge about the possibility of chronic disease. These initiatives involve some economic input, but they have the potential to reduce NHS spending and reduce suffering in the local area. Morgan et al (2007) back up this approach with findings from the Canadian healthcare system. This study finds that preventative healthcare is needed in any approach to tackling the huge numbers of chronic disease sufferers, particularly by improving the management of healthcare providers. Morgan et al (2007) suggest that there needs to be a higher rate of implementation of strategies, as splitting the healthcare services into trusts (as they are in the NHS) can mean that some areas have lower rates of suffering from chronic disease. The research also highlights the importance of patients not being ‘lost in the system’ (p3) because this can mean that preventative healthcare is not reaching those who need it most. Epping-Jordan et al (2004) describe the Chronic Care Model (CCM) which involves the Innovative Care for Chronic Conditions (ICCC) framework. These work on tackling chronic conditions from a holistic perspective, by splitting areas of focus into three main components. The first is the micro level, which involves providing adequate care to the patient and the patient’s family, which is increasingly important as chronic conditions can require long-term care. The second is the meso level, which tackles the healthcare organizations and the community, by trying to focus on educating these areas in the problems of chronic healthcare and the main aspects of preventative care. This can be through advertisements or directives aimed at educating the healthcare providers on the best advice to give patients and potential patients. The final is the macro level, which targets policy makers. These are increasingly important as the government has huge influence on campaigns towards better healthcare. Policies can target requirements for doctors to be educated on chronic conditions and their care, as well as government-sponsored advertising schemes such as the 5-a-day scheme advertised across the UK (Subar et al, 2005). Socio-Political Context of Long-Term Condition Management As previously mentioned, long-term conditions are becoming increasingly important on a global scale (Epping-Jordan et al, 2004). The socio-political context of these conditions is therefore going to evolve with time, especially as they become more common. In a political context, it is important for politicians to recognize the needs of those with chronic care and to move policies towards the preventative anticipatory method of care (Meyers et al, 2004). Incorporating all the information above, it seems that this is the best way to provide care for the increasing numbers of chronic illness sufferers in the country, and could help prevent the diagnosis of more. Policy making is also important in that it can ensure that all areas of the UK are receiving similar levels and styles of care, throughout the NHS. As NHS Health Scotland (2011) identified, there is a discrepancy between the poorest areas in Scotland and the wealthiest, and this can be seen across the UK. Policy directives could help to combat these problems and therefore reduce the number of sufferers. This suggests that the political context needs to be included in any analysis of chronic conditions. The social context of long-term condition management is perhaps more complex. It is important that, socially, communities and individuals are alerted to the problems of chronic conditions and how they can be avoided or improved (Landon et al, 2007). This may require significant effort on the part of the NHS Trusts, particularly as this might require significant financial input. It will also be interesting to see how the social context adapts as more and more people are familiar with a loved one that suffers from a chronic disease as the population ages and obesity increases. This should change the stigma associated with chronic disease somewhat. There are other social issues that need to be tackled, particularly those associated with chronic mental illness. Although there have been a number of government-funded projects aimed at highlighting the common nature and difficulties facing mental illness sufferers (Byrne, 2000), there is still a significant amount of stigma associated with these problems. Continuing work in this area should help this context, and perhaps political influence may have a beneficial effect also. There are a number of other chronic illnesses such as fibromyalgia and chronic fatigue syndrome which are not completely accepted by the medical community (Anderson & Ferrans, 1997), and the socio-political context of these may need to improve before true acceptance for sufferers is recognized. Evidently, socio-political contexts are hard to predict, but there do need to be significant changes in the area to help improve compliance and acceptance for sufferers of long-term conditions. Conclusions There are a number of conclusions that can be drawn. Firstly, the NHS clearly has some problems in targeting chronic health problems, as the model currently tends to focus on a reactive healthcare model which benefits those suffering from acute syndromes. This is essentially a way of providing healthcare which means that medication is given one symptoms are apparent, which may not benefit chronic conditions such as diabetes. Moving to a anticipatory model of care comes with some problems, but as the number of individuals suffering from a chronic conditions is continually rising, it would be hugely beneficial to patients and the NHS alike. There are a number of perspectives that can be used to look at this. The first is the micro model, which involves tackling the individual and close relatives. The second works on the meso level, which essentially targets communities and healthcare, and the macro level targets policy making. Combatting these three areas will ensure that healthcare is provided holistically, involving every possible area which could benefit chronic condition sufferers. This has been shown to be the most effective way of targeting chronic disease. More research should be completed on how best to work this in reality, but it seems that the contemporary shift towards these models is appropriate and beneficial to all involved. References Anderson, J.S., and C.E. Ferrans. ‘The Quality of Life of Persons with Chronic Fatigue Syndrome’. The Journal of nervous and mental disease 185.6 (1997): 359. Print. Bell, V., and D. Troxel. The Best Friends Approach to Alzheimer’s Care. Health Professions Press Baltimore, Maryland, 1997. Print. Byrne, P. ‘Stigma of Mental Illness and Ways of Diminishing It’. Advances in Psychiatric Treatment 6.1 (2000): 65–72. Print. 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