16-17 - PUBLIC HEALTH: The good life?

Good health is a lifelong process. Many of the most critical behaviours are established in early childhood and need reinforcing at each stage of life.

The health of the British population sadly lags behind many other developed countries and is beset by disparities among racial, ethnic and socially disadvantaged groups.

Recognition that this problem cannot be solved only by better and more accessible medical care has led to increased interest in ‘population health’ among government ministers and commissioners. Indeed they are also becoming more focused on its underlying determinants – behaviours and social and environmental conditions.

Yet the NHS’s approach to health largely remains rooted in a decades-old ethos of treating the symptom, rather than the person. The modern antidote to this is a facilitative, digital solution that can integrate multiple health service, boost well-being and connect clinical data to provide deep meaningful, actionable insights and dynamic patient engagement services.

The UK population is becoming less healthy. Obese people will outnumber those with a healthy weight within five years. It is predicted that 5.5 million people will have diabetes in the UK by 2030. Diagnosis of chronic obstructive pulmonary disease has increased by 27% in the last decade to 1.2 million people.

For integrated care systems (ICS) it is now essential to put in place solutions that address this population health crisis. Prevention strategies have been on the agenda for more than a decade but, to date, have failed to deliver.

The burden falls heavily on primary care services and, given the current GP crisis, there is growing consensus that the focus on increasing the number of appointments available is the wrong approach.

With limited GP numbers, there is only one way to increase the number of annual appointments by 50 million – reduce appointment length. And that, by default, will reinforce GPs’ requests for patients to only raise one health concern per appointment, an approach that completely flies in the face of accepted wisdom regarding comorbidities and preventative care.

Obese individuals require more than a one-off referral to weight management. Are they also prediabetic and require access to a dietician with diabetes expertise? Are they also depressed? What, indeed, is the underlying cause of the obesity?

With growing evidence that chemical pollution is a significant contributor to obesity, an ICS’s specific environmental factors will increasingly influence obesity understanding.

Similarly with smoking cessation. Smokers are more prone to depression – as are people with diabetes. Failing to recognise and address a smoker’s depression will affect any attempts to stop smoking, especially if the individual is isolated and lonely.

Meanwhile, the recent news that nearly one million patients with insomnia will be prescribed a £45 self-help app instead of sleeping pills on the NHS underlines the problem facing GPs. While this six-week digital therapy programme is the first-line treatment, it provides GPs with no opportunities to address any underlying cause of the insomnia.

From perimenopause to sleep apnoea – which is also linked to type 2 diabetes – treating the patient, rather than the individual symptoms, is clearly far more effective. But, as GPs increasingly insist, there is not enough time.

Rapid access to GPs with more, shorter appointments will work for those requiring occasional support. But with 40% of GP appointments in England consisting of ‘frequent attenders’, the elderly and those with multiple, complex conditions, it is the addition of time and personal, preventative care that will make the biggest difference.

Instead, these individuals are compelled to book appointment after appointment to discuss each of their conditions – a process that is hugely inefficient for GPs, massively frustrating for patients and devastating for patient outcomes.

A better, joined-up approach would not only reduce the burden on GPs but also improve patient outcomes. So how can it be achieved? Some of the foundations are in place. The ICS model is positive, bringing together diverse providers of both clinical and social care to support individuals with complex needs, tackle inequalities in outcome, experiences and access, and improve outcomes in population health and healthcare.

Furthermore, the investment in digital health over the past decade has demonstrated the power of information and tools to transform care. Patients are being empowered with apps to record their blood pressure or track their insulin levels. They are being provided with access to dedicated specialist services, such as weight loss and diabetes management.

Right now, however, these services are still commissioned separately and each patient condition is managed separately. There is no holistic, joined-up information and, as a result, no holistic, joined-up care.

The ICS concept is compelling but it is vital to break down the silos between services and truly understand how the population needs to better interact with the system as a whole. Just as hospital Trusts have well established multidisciplinary teams that work together to find the best holistic solution for each patient, ICSs require a single case management system that captures all patient interactions with these primary care services. Effectively, a single patient record and single patient view accessible to multiple services that enables engagement in a similarly holistic way.

At an individual patient level, the complete overview ensures clinicians are made aware of any individual requiring specific support. Plus, rather than being compelled to manage multiple apps and services and repeating the same information time and again, patients can be offered just one, integrated solution supporting self-management, education and access to experts across all their conditions and medical needs.

At a strategic ICS level, the ability to capture and analyse all patient interactions with these services will enable a better understanding of the community. With insight into population health provided by exploring the overlap in conditions, the influencing factors for obesity, for example, ICSs can create best practice in supporting effective change that reflects their broader social and care remit.

Have obesity levels in the community increased following the addition of new take aways on the high street and, if so, can public health departments take action? Have social prescribing activities had a positive impact on COPD patients who are experiencing isolation and loneliness?

Are smoking cessation programmes that also support weight management more effective at achieving long-term behavioural change and, if so, are there demographic or ethnic differences that need to be understood and incorporated into personalised care packages?

How can the ICS nudge behavioural change and encourage the use of relevant services to improve patient outcomes and encourage self-care? The opportunities to use digital to transform health are within reach – but only if ICSs have a complete, end to end understanding.

Pulling together essential insight and service provision into a single, joined-up solution will reduce the number of interactions required by patients and ensure the interaction is more personal, targeted and beneficial. It will remove the revolving door of patients for clinicians and provide the information required to quickly deliver the education, support and care each individual needs.

It is time to elevate the conversation around digital health. Forget about individual service solutions. Stop thinking about symptoms. Focus on delivering a complete population health solution.

With a single platform and patient-facing app that support diverse patient needs, the process will clearly become more efficient, relevant, targeted and, from a clinician perspective, valuable.

Ultimately, it can only be achieved if people are at the heart of it.

The good life?

Wrong direction

Essential time

Preventative care

Building trust

Final analysis