100 years of living science Chronic disease management in primary care: lessons to be learnt Dr Shamini Gnani November 2007, Mauritius

Outline of seminar  Background  Chronic disease management strategies  Case study – primary care and diabetes  Discussion

Challenges of chronic diseases  Epidemiological transition  Excess ill health among the poor  Healthcare systems  Evidence of chronic disease management

WHO Global Burden of Disease study :2002

Mauritius burden of disease

UK 2001 Census population pyramid

Republic of Mauritius population pyramid 1996 & 2006

UK National Health Service Funding system central taxation GDP 8.1% (£68 billion) GDP will be % 2022/23 Delivery system Moving to mixed provision 10,465 general practices 41,574 family doctors

Alma-Ata 6 Declaration: VI ‘ Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self- reliance and self-determination. It forms an integral part both of the country’s health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process.’ International Conference on Primary Health Care, USSR, September 1978

Primary health care: definition  First contact access  Person focused care over time  Comprehensiveness  Coordination of care  Family orientation or community centeredness  Cultural competence

Defining chronic disease  Long term health condition > 6 months  Range of complications, remain dormant or require continual monitoring  Management to reduce symptom severity and prognosis is possible in many conditions.  60% of UK adults report a chronic illness  8.8m people having long term illnesses that severely limit them day to day

Impact on primary care and health services  80% GP consultations  Over 60% of hospital beds days  Two thirds of patients admitted as medical emergencies have exacerbation of chronic disease or have chronic disease  Patients >1 condition costs are 6x more  15% of people with three or more problems =almost 30% of inpatient days  High intensive users  10% of inpatients account for 55% of inpatient days  Very high intensive users  5% of inpatients account for 40% of inpatient days

Chronic disease management pyramid Level 1 [patients manage own condition] Majority; small improvements huge impact Level 2 [single disease management] Multi-disciplinary teams High quality evidence based care protocols and pathways Good IT systems Level 3 [multi-disease] Case management Source: Department of Health (2004) Improving chronic disease management

Barriers in primary care  Time constraints in primary care  Limit delivery of preventive services  Acute symptoms & patient concerns crowd out less urgent need to improve optimal management of chronic illness  Patients not adequately taught to self-care  Limited orientation to disease monitoring  Lack of ‘office’ systems for chronic disease care

Strategies for effective management in primary care  Disease registers  Computer support & templates  Effective prescribing & medicine management  Lifestyle prevention  Self care & patient empowerment

Prescribing and medicines management  Up to 50% fail to take medicines properly*  20% type 2 diabetes fail to take medicines at least once a week*  1:1 reviews  Help simplify medication, encourage effective use  Protocols, guidelines & tools  National Library for Health  Wider prescribing responsibility  nurses, pharmaceutical advisers & stop smoking services Source: Royal Pharmaceutical Society

Prescribing and medicines management: UK  Net ingredient cost of all prescriptions = £8,197 million  752 million dispensed prescriptions (increase 55%,1996)  Average net ingredient cost/prescription item = £10.90  Leading prescription item dispensed & cost = cardiovascular system  Average 14.8 prescription items/ capita (10,1996)  Elderly received 40.8 items per head in 2006 (21.2,1996)  88% of all dispensed prescription were free in 2006 (86%,1996)

Prevention: lifestyle and modifiable risk factors  Exercise  Obesity  Primary care intervention (Department of Health)  Smoking  NHS stop smoking services  Alcohol  Cholesterol  Hypertension

Self care and patient empowerment  Diabetic patient 3 hours/year with health professional  8757 hours/year self manage  Provide access information to patients  Advise patients on self monitoring self management programmes  Evidence supports that it leads to Improves psychological well-being Pain reduction Decreases depression levels

Practice implementation  Using nursing skills  patient education & self care  develop practice nurse chronic disease management role  nurse prescribing guidance  Effective computer templates use  Implement NICE guidelines on drugs  Review practice prescribing  Forum to discuss medication & difficult patients

Case example: diabetes mellitus  UK 4%  Brent 6%  Diabetes prevalence = 10-12% [1987 survey]  Impaired glucose tolerance =15-17%  Predicted increase of diabetes  From 111,000 (2000) to 233,000 (2030)

Break out session

Identify chronic disease management strategies that should be introduced in Mauritius including -strengths and benefits -barriers