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October 16, 2018
Relentless patient focus – the only route to structured disease management success?
By: Jagdip Grewal

Here’s a figure for you: in a typical STP of 1 million people, around 300,000 patients will have a long-term condition (LTC).1 And when the risk factors for disease progression aren’t properly addressed, the resulting crises create incredibly high demand on the system, currently accounting for 50 percent of all GP appointments, nearly two-thirds of outpatient appointments and more than 70percent of inpatient bed days.2

In England, 15 million patients with long-term conditions such as diabetes, arthritis and asthma, equating to 30 percent of the population, account for 70 percent of annual NHS expenditure.3 However, since the 1990s, advocating a structured, person-centric approach, current disease management is highly variable in terms of approach, quality and outcomes . The above figures show we don’t have the ‘control’ needed.

If we’re to properly address the management of these diseases we need a relentless focus on the patient, and I believe much more needs to be done. Factors affecting disease progression must be tackled in parallel to enable patients to get ‘control’. It’s clear to me that the right approach is one that continues to focus on four areas:

  • Consistent application of clinical best practice

  • Addressing lifestyle risk factors often deeply engrained in patient behaviour and need

  • Personalised care planning with patients involved in decisions about their care

  • Proactive care delivery to support patients when needed

I understand the complexity and effort involved in designing, implementing and maintaining structured disease management programmes is considerable. This includes governance to manage best practice templates and clinical and business rules; the need to schedule and coordinate an integrated care team; compliance to manage variance against the care plan; end-to-end clinical care delivery with proactive support provided when needed; and reporting on service performance and patient outcomes.

Even with dedicated clinicians going the extra mile for patients, this complexity is insurmountable for already stretched clinical services. Digital solutions that enable, automate and standardise three critical elements will provide much needed help –namely:

  1. Personalised care plans that incorporate clinical best practice, patient education and self-care tactics across multiple domains, including health, social, psychological and lifestyle. Tailored to the patient’s risks and needs, these plans switch care provision from being reactive and static to proactive coaching and prevention via bite-size patient encounters.

  2. A clinically-led design of the clinical and business rules to develop tactics, such as scheduling care interactions across teams and communication channels including face-to-face, phone, email and SMS interactions, with decision support to standardise care delivery.

  3. Patient involvement and commitment to the ‘programme’ with clear expectations and accountability agreed for clinical services and patients, with automated communications reinforcing behaviours and escalating non-compliance.

There’s no simple answer to implementing structured disease management with all of the required capabilities or necessary conditions in place. Perhaps start your journey by considering where your organisation is on the diagram below. And if you’d like to discuss the issues raised further, please get in touch.

Click to expand.


1 Long Term Conditions Compendium of Information, Third Edition, DoH, 30 May 2012
2 Long Term Conditions Compendium of Information, Third Edition, DoH, 30 May 2012
3 Managing people with long-term conditions, King’s Fund, An Inquiry into the Quality of General Practice in England, 2010

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