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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