Meeting the needs of chronically ill people
BMJ 2001; 323 doi: https://doi.org/10.1136/bmj.323.7319.945 (Published 27 October 2001) Cite this as: BMJ 2001;323:945
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Sir,
Chronic disease management throws up multiple problems to doctors and
their patients.
Until recently doctors have been trained to respond to acute symptoms
and done relatively little to correct underlying causes. Patients have
also been advised to attend when they have symptoms rather than when they
are apparently well.
So, for example, a patient with uncontrolled diabetes presents with
balanitis or cellulitis but fails to attend his routine clinic appointment
with the nurse. He says, "I didn't need to see her then. I was well then."
His diabetic control has to be squeezed into the time left after treating
his presenting symptom.
If GPs (and other specialists) are to become effective agents for
chronic disease management we have to stop spending our time reacting to
events and start anticipating and preventing them. We need to alter our
frames of reference to stop overvaluing technical brilliance in treating
acute events and instead to start to reward people for saving the need for
such brilliance to be displayed.
This is a significant change to medical value systems and many
doctors (and patients)will prefer to cling to the wreckage of the outdated
model of acute reactive medicine.
We need to develop systems of working that will allow us to make this
change and in general practice the first step must be to increase the
length of consultations.
Competing interests: No competing interests
Peter Lapsley points out that our theme issue on chronic disease
included nothing on skin disease. We will make sure that the next theme
issue on chronic disease does, and we will also consider a theme issue
specifically on skin disease. Such an issue might consider why skin
disease is so consistently forgotten.
Richard Smith, Editor, BMJ
Competing interests: No competing interests
Sir
As an umbrella organisation representing the interests of skin
patients, we were disappointed if not surprised that your 27 September
issue, with its focus on chronic illness, should have made no mention of
skin diseases, amongst the commonest of all groups of long-term medical
conditions.
Skin diseases account for around 15 percent of a GP’s workload. Six
percent of GP prescriptions relate to skin disease and 4 percent of NHS
retail sales are for dermatology prescription-only medicines.
GP consultations reflect only a fraction of the problem. Skin
diseases affect around 33 percent of the population at any one time. The
first ports of call for many people seeking help with them are often
pharmacists, NHS Direct or the internet. Of the 66% of calls to NHS
Direct that are triaged by nurses, almost 8% relate to skin problems
Fatal conditions like skin cancer and Epidermolysis Bullosa aside,
the quality of life issues associated with skin diseases are often very
serious, including severe disruption of family life, teasing and bullying
in schools, difficulty in obtaining employment, prejudice at work and
severe problems in forming social relationships. There is good research
evidence to show significant increases in behavioural problems in children
with skin diseases and similarly significantly increased suicide rates in
adults.
All this being so, we find it extraordinary that the medical
profession’s dismissiveness of skin diseases should be so clearly
evidenced both in an almost total lack of dermatology training for
pharmacists, nurses and general practitioners and in the BMJ’s consistent
failure to consider skin diseases when focussing on chronic illness.
Yours sincerely
Peter Lapsley
Chief Executive
The Skin Care Campaign
Competing interests: No competing interests
In my view my patients in a deprived Cumbria coastal town are getting
unhealthier. We pour vast energy into chronic disease management. Single
issue groups forget that many patients in deprived towns acquire lists of
chronic diseases. Add in the inevitable chronic disease of old age and for
many of our patients, attending and managing their chronic disease(s)
becomes synonymous with life itself. Endless mildly abnormal blood
results, 20 visits to the GP a year, telephone follow up and contradictory
messages relayed from the different clinics and hospital letters leads to
groaning records (thank god we are computerised)and for even the best GPs
complete bewilderment as to how to co-ordinate all this. The chances of
the patients understanding even a small proportion of the issues are nil.
The surgery becomes like a second home to many patients and the GP and
nurse parental figures. I watch as patients weave their chronic disease(s)
into their lives and actually sometimes probably enjoy the interest of the
whole process: probably beats pottering in the garden and watching
television.
In my view we are increasingly taking over vast tracts of some patients
lives. When will our disasterous lifestyle be addressed at a higher level.
Inactivity, poor diet, endless occupational stress, emotional incompetence
caused by television and other media, alcohol and smoking .... These are
the cause of most chronic disease and should be addressed at a higher
level than the GPs surgery. The GP is increasingly treating life itself as
a disease! There must be more to chronic disease than endless clinics,
blood tests and contact with the health service: it is just not
sustainable.
Competing interests: No competing interests
Dear Editor,
Dan's response to Wagners article argues for low intensity general
hospitals. They already exist as under-resourced cottage hospitals in the
UK, staffed by General Practitioners who are already looking after the
same patients at home. GPs are providing the continuity of care for these
patients. After a decade of closing down cottage hospitals the Department
of Health is now less opposed to this vital buffer. Perhaps the future is
to develop these facilities and put in place a system of education and
training for GPs in these specialities in order to produce patient centred
outcomes.
Competing interests: No competing interests
While this article reffers to the management of the chronically ill
at home and in the community the problem of hospital care merits a special
consideration.I reffer mainly to patients who have been already given a
full diagnostic work-up and need hospitalisation for acute conditions
without further work-up. Elderly patients with pneumonia, heart failure,
diabetes control, urinary infections etc may need a medical and nursing
care which is more understanding of their chronic limitations and
problems. We all remember "The House of God " and the fate of the "Gomers"
. But in hospitals that are specialising in caring for the elderly and the
chronically ill these patients may receive better personal care and at
the same time cost the public half of what it costs in the "general
hospital" with all its overhead. It is about time that the concept of the
"Low Intensity General Hospital" becomes a reality. Such hospital should
not be restricted to the care of "nursing cases" , rather than that it
should become a multispecialties institution. A combination of services of
Internal Medicine, Geriartrics, Rheumatology' Psychiatry, Rehabilitation
etc will "upgrade" the status of these hospitals and attract both doctors,
nurses and patients. They will relieve the burden of the Medical Wards in
winter and will save very important public resources. They should
establish good clinical and nursing cooperation with the Community in
order to improve the continuity of care.The traditional Acute Care General
Hospitals will have to adjust to the changing world but they may profit
too if they ccoperate with such "low intensity hospitals". For example an
X-Ray technician and the laboratory of the "low intensity hospital" that
is connected via "telemedicine" to the Regional Hospital may benefit both
facilities and their patients.
Competing interests: No competing interests
The System Needs Managing Better
Many doctors would do well to remember that patients with chronic
diseases are not always socially deprived, often articulate when their
condition is not debilitating their cognitive function and that they
cannot actually help being ill. They might also consider that depression
is often brought on by the frustration of dealing with the medical system
and attitudes, more so than the condition.
Could anyone imagine a well person being expected to recover from the
effects of accidents or acute illnesses without necessary physiotherapy,
treatments or further follow ups, yet it is undoubtedly expected of people
who have a chronic condition, despite the knowledge that such incidents
can exuberate conditions. Why, is it because doctors are psychologically
compartmentalising events into allowable chunks?
Condition management is also pointless if a patient cannot access the
medical services at times when they need it most. Patients also need to
see the same doctor whenever possible, even if it means altering other
patients appointments. It is not an effective use of time and it is not
fair on the patient if they have to endure a succession of new faces and
temperaments each time they have an emergency. Imagine how dreadful it
must be for a patient of different cultural values, or from another
country, to be facing the prospect of yet another face, when English
people find the system so daunting themselves.
This is a time when affordable treatment choices for chronic
conditions are being withheld from people because doctors have habitual
prescribing habits, when hands on therapies are still scoffed at, and when
GP's cannot associate and disassociate conditions appropriately for the
benefit of their patients. There is also a denial of patient individuality
due to a strict adherence to scientifically unsubstantiated protocols.
I think that the system is the chronic condition that needs
'managing'.
Competing interests: No competing interests