The control of chronic disease in the 21st century: The need for an integrated approach

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The control of chronic disease in the 21st
century The need for an integrated approach

• Martin McKee
• European Observatory on Health Systems and
  Policies
• London School of Hygiene and Tropical Medicine

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A changing world
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New ways of killing
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Health care before the 20th century

• Hospitals
• Places of sanctuary
• Patients patiently waiting for death
• Surgeons
• Part-time barbers
• Judged by speed of completing amputations
• Physicians
• Masters of watchful waiting
• Judicious application of herbal remedies
• Nurses
• Sisters of mercy

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Type I diabetesThen and now

• Discovery of insulin changed a rapidly fatal
  disease of childhood into a lifelong disorder
• Now compatable with a normal life span, but large
  differences in actual attainment
• Healthy survival requires co-ordination of
  efforts by many people and organisations
• Pharmaceutical supply and distribution
• Primary care
• Specialist care
• Self care

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Age specific death rates in cohorts of young
diabetics
Derived from DERI, 1995 Laing et al., 1999
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Diabetes - mortality incidence
Nolte, Bain, McKee. Diabetes Care 2006
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A tale of two countries
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The effects of health care system collapse
Deaths from diabetes under age 50 in Ukraine
3.0
2.5
2.0
deaths/100,000
1.5
1.0
0.5
0.0
1965
1970
1975
1980
1985
1990
1995
2000
Source INED/ CHDE
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The same but different

• Diabetes
• Life sustaining treatment
• Insulin
• Monitoring
• Blood sugar
• Complications
• Retinopathy
• Nephropathy
• IHD

• AIDS
• Life sustaining treatment
• Anti-retrovirals
• Monitoring
• CD4
• Complications
• PCP
• Kaposis sarcoma
• IHD

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Prevention is better than cure
Projections of future expenditure on UK NHS under
three scenarios

50 bn
Fully engaged major commitment to health
improvement
Source Wanless Report
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Alternative settings
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The informed patient
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Evidence rather than intuition
OK, well vote. How many say the heart has four
chambers?
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Reaching out to those in need

• Doctors tend to gather where the climate is
  healthy... and where the patients can pay for
  their services
• Ivan Illich
• "the availability of good medical care tends to
  vary inversely with the need for it in the
  population served."
• Julian Tudor Hart

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The pace of change look around you
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Dont forget the workers
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(No Transcript)
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www.3four50.com
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The Chronic Care model
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What works?
Mortality from diabetes

• Few evaluations
• Even fewer studies of patients with multiple
  disorders
• Results may be context specific

USA
Europe
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Key themes

• Effectiveness
• Responsiveness
• Self-management
• Integration

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The success of the marketAn example from the
UK

• Break up of telephone directory enquiry service
• Millions spent on marketing by new operators
• Recouped by much high charges
• Quality of service appalling
• Customer confusion
• Collapse in demand
• 118118 (market leader) abandoning product
• A complete disaster

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to say nothing about.

• Rail privatisation
• Government subsidy double that when under state
  ownership
• Fares escalating far above inflation
• Rail crashes due to defective maintenance
• Loss-making infrastructure company taken back
  under state ownership
• and then improves service and makes a profit

and The Skye Toll Bridge Private Finance
Initiative Devonport Dock Yard and many others
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Modernising the English NHS

• We had to destroy the village to save it
• Peter Arnett quoting unnamed US Army
• officer in Vietnam

• Modernisation
• or The Great Leap Forward

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Looking ahead

• Chronic diseases will pose some of the greatest
  challenges to health systems in the 21st century
• This is our chance to make a difference