January 04, 2015

Learning from the Limeys

Judging by what you read in the press, you might think that Britain’s National Health Service (NHS) provides second rate medical care. When Senator Ted Kennedy was diagnosed with a malignant brain tumor in 2008, Republican Senator Chuck Grassley of Iowa opined, “I don’t know for sure. But I’ve heard several senators say that ted Kennedy, with a brain tumor, being 77 years old…if he were in England, would not be treated for his disease, because…when you get to be 77, your life is considered less valuable under those systems.” 

Anyone who says anything good about the NHS risks being attacked by the political right. Founder of the quality improvement think tank, the Institute for Health Improvement, Don Berwick, learned this the hard way when he was lambasted by arch-conservative pundit, Betsy McCaughey for favorable remarks he made as a guest of honor at the 60th birthday celebration for the British National Health Service. McCaughey best known for labeling advance care planning as creating “death panels,” and thus consigning to the trash any proposal that would have enabled Medicare to pay for discussions between patients and doctors about their preferences for end of life care, asserted that Berwick liked the NHS because it promotes “central planning, frugality, wealth redistribution and rationing.” As a result of attacks like this, Berwick was pilloried by the American right and unable to be confirmed by the Senate as Administrator for the Centers for Medicare and Medicaid Services (CMS).

The British, however, are generally very proud of their health care system, with 71% of them maintaining it is one of the “best in the world.” They have reason to be proud. A more objective evaluation than that of McCaughey and her ilk, prepared by the Commonwealth Fund, compared the performance of 11 developed countries and found that the UK’s overall ranking was #1—and the US’s was #11. And in the arena of geriatric care, the UK is miles ahead.

A new report being released this month by the British Geriatrics Society, Fit for Frailty, is the second of a two-part series. Part I, which came out in June of 2014, was a practice guideline for clinicians caring for older people in the community. It highlighted the importance of recognizing frailty and of emphasized what doctors should do with the individual frail patients in their care. Part II presents recommendations for a community response to frailty, focusing on the services and systems that should be put in place to promote quality of life for this vulnerable population. Highlighting just a few of the report’s conclusions should make clear just how much we have to learn from the limeys.

Fit for Frailty argues for the creation of an individualized (or as they prefer, individualized) “Care and Support” plan. This is a form of advance care planning that squarely addresses the contradiction inherent in most American versions of advance care planning, the conflict between current and future health status. American advance directives make most sense for people who are entirely healthy when they fill them out and are anticipating the remote possibility that they will develop a catastrophic, irreversible illness. Think Karen Quinlan, Nancy Cruzan, Terri Schiavo—all cases of young, healthy women who abruptly lost consciousness and subsequently were diagnosed as being in a persistent vegetative, and who didn’t have a clear written advance directive. 

But older people who engage in advance planning are often already in a state of chronically ill health. What they have to think about is not just what they would want if they suddenly developed a new, overwhelmingly bad disease (say the person with heart failure, diabetes, and chronic pulmonary disease who is found to have lung cancer), but also what the approach to treatment should be if they develop an entirely predictable, common complication of the diseases they already have (say the person with heart failure, diabetes, and chronic pulmonary disease who comes down with the flu or pneumonia).

In recognition of geriatric realities, the Fit for Frailty report has six parts: naming the person responsible for coordinating their care (this is different from designating a health care proxy and refers, rather, to establishing a primary care physician); a health and social care summary (a list of diagnoses, medications, and social situation—recognizing that how best to care for someone depends both on what he’s got wrong with him and the resources available to him as well, I would add, as his goals of care); a wellbeing maintenance plan (including the goals of care, designating who is responsible for doing what on a day to day basis); an escalation plan (describing what a patient and caregiver need to look out for and whom to call or what to do if there is a problem); an urgent care plan (addressing crisis management and specifically dealing with preferences for hospitalization); and an end of life care plan (articulating the preferred place of dying and whether to have an emergency medical kit in place).

Fit for Frailty also advocates developing “pathways of care” for the different frailty syndromes, such as falls or delirium. This means plotting out what- should-happen-if, not for all possible health problems, but for the most common situations that frail elders might find themselves in. And it means assuring that the necessary systems are in place to allow for implementation of the plan. This is crucial since current practice is geared to implementing only one kind of plan, a plan that assuring that acutely ill individuals receive maximally aggressive medical care as expeditiously as possible. If the plan calls for something else, for example evaluation and treatment at home, a system has to exist to accommodate this approach. As Fit for Frailty says, very matter-of-factly, keeping a frail old person at home when he or she get sick should be as easy as arranging hospital admission. Right now, setting up all the necessary services is much more complicated than calling 911. Keeping a frail person at home requires making a diagnosis. Right now, the best way to make a diagnosis is to send the patient to the hospital emergency department. Keeping a frail person at home necessitates skilled health staff to provide ongoing supervision and support of care. Right now, the easiest way to get daily nursing and social work care is by hospitalization.

Creating a “care and support plan” and putting in place a system for providing care when acute illness strikes, the acute illnesses that are predictable complications of frailty,  really shouldn’t be so difficult. The Brits are going to do it. We should, too.

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