97
If the mixed economy is to continue, of degree equity between the sectors is essential, and health authorities have been urged to come clean about their responsibilities in this respect.8 Is community care a viable option? There comes a level of infirmity at which such care turns into
ernphasised.’ some
expensive community neglect.4 Many people over ninety years of age lead active and independent lives,9 and it has been argued that preventive medicine and increasing affluence will lead to a compression of morbidity and a reduction in end-of-life dependency.10 But the fact that the numbers of people in their eighties and nineties are rising inevitably means that there will be more irreversibly disabled and dependent individuals who are likely to spend longer periods of time requiring 24-hour support.11.12 The dwindling stock of extended-care beds and local authority residential home places leaves the health and social services departments exceedingly poorly equipped to face the "geriatric imperative" .13,14 Private long-term-care insurance has not been successful in the USA and there is no reason to suppose it would do any better in the UK.15 There is no doubt that we will continue to need long-term care, both for physical and for psychiatric dependency, and that it matters greatly-to patients and their carers and to primary-care teams and acute hospital services. The question of who will pay requires urgent attention. 1. Anon. Increased suffering for the elderly on the NHS. Guardian, Oct 10, 1991. 2. Coni NK. Alive and well: geriatric medicine in the UK in 1984. Health Policy 1985; 5: 173-81. 3. Philp I, Mutch WJ, Ballinger BR, Boyd L. A comparison of care in private nursing homes, geriatric and psychogeriatric hospitals. Int J Genatr Psychiatry 1991; 6: 253-58. 4. Optit LJ. Domiciliary care for the elderly sick—economy or neglect? Br Med J 1977; i: 30-33. 5. Henwood M, Jowell T, Wistow G. Briefing paper 12: all things come (to those who wait). Causes and consequences of the community care delays. London: King’s Fund, 1991. 6. Audit Commission. Making a reality of community care. London: HM Stationery Office, 1986. 7. Livesley B. Cost-benefit consideration in the treatment of elderly people. Drugs Aging 1991; 1: 249-53. 8. Health and Social Security Select Committees. The financing of private residential care and nursing home fees. London: HM Stationery Office, 1991. 9. Bury M, Holme A. Life after ninety. London: Routledge, 1991. 10. Fries JF. Aging, natural death and the compression of morbidity. N Engl J Med 1980; 303: 130-35. 11. Stout RW, Crawford V. Active life expectancy and terminal dependency: trends in long term geriatric care over 33 years. Lancet 1988; i: 281-83. 12. Brody JA. Prospects for an ageing population. Nature 1985; 315: 463-66. 13. Laing W, Hall M. Agenda for health 1991: the challenges of ageing. London: Association of British Pharmaceutical Industries, 1991. 14. Anon. Discontinuing care. London: Age Concern, 1991. 15. Driver D. Successful ageing. The Times, Nov 4, 1991.
Diabetes practice: the information gap For those whose clinical practice includes a substantial proportion of diabetic patients the workload seems to increase inexorably without a concomitant change in resources. Yet we are told that
developed countries diabetic patients may be responsible for 4-5 % of national health care expenditure.1-3 So is the impression illusory? Is it merely that there has been a huge change in diabetes care during the past decade-eg, with respect to blood sugar monitoring, diet, intensified insulin therapy, treatment of complications, diabetes specialist nurses, patient education, management of diabetic pregnancy, and organisation of diabetes care? Perhaps it is a consequence of the scramble to keep ahead of the startling proliferation of charters, guidelines, and consensus statements.4-8 Or maybe there is an increasing mismatch between expectations and in
The truth is that most of us have not the faintest idea because we spend all our time reacting to a rapidly and unpredictably changing world. We seldom take even a few moments to consider whether we are doing what we should be doing now, far less ponder the future. This pattern is equally true for funding agencies. Such a passive approach is unlikely to achieve the best use of available resources. A report commissioned in 1988 by the Dutch Government attempts to address many of these issues.9 Discussion of the views of health care professionals on organisation and outcome of diabetes health care is mostly unexceptional, reflecting existing knowledge and opinion on best practice. Quality of life, which is often overlooked in chronic disease management, is’identified as a key focus for services, in addition to traditional medical outcomes such as blindness and amputation. Disappointingly, however, no patients’ views were sought. Diabetic patients are knowledgeable consumers who are in lifelong contact with the services provided for them; their opinions are important for policy developments. Diabetes in pregnancy is also largely ignored. Nevertheless, four key points emerge that are of general relevance to the future provision of diabetes care. First, there is a need for government policies with respect to diabetes mellitus. The Dutch are probably entirely representative in having none. The report suggests that central policy objectives should include measures that lead to increased self-care and early detection of complications. Diabetes specialist nurses, better patient education and information facilities, community-based dieticians, regular clinic review for evaluation of metabolic control, and early detection of complications and extra training of medical and paramedical health care professionals are given as examples of proven systems. This conclusion is entirely consistent with all the existing charters, consensus documents, protocols, &c. Nevertheless, central support is essential if patchy practice is to be made more consistent. Second, the report identifies the likelihood of a very considerable increase in the number of diabetic patients during the next fifteen years. Calculations were based on the reasonable assumption that the incidence of insulin-dependent diabetes mellitus (IDDM) would continue to increase slowly in young resources.
98
people and that, within the time-frame considered (1990-2005), public health/health education measures would be unlikely to alter the prevalence of obesity appreciably. Existing and expected demographic changes then imply that in the Netherlands there will be a slight increase in IDDM and a large increase in non-insulin dependent diabetes (NIDDM); overall, the increase could be as much as 40% (or 75% compared with 1980), the largest changes occurring in the 45-65 and over-80 age groups. Overall prevalence would then be about 2 % of the population, about 33 % of whom would be treated with diet alone, 44% with tablets, and 23% with insulin. Organising services for the care of patients with diabetes involves many people and agencies--eg, hospital-based and primary care diabetes teams, community services, patients themselves, with whom responsibility for much day-to-day management rests, and the general population among whom they live and work. Such large numerical changes will have appreciable effects on all these groups. Projections for other developed countries are likely to resemble the Dutch calculations; for developing countries, in which life expectancy is still increasing rapidly, they may be even more striking. Third, the report identifies the need to develop a diabetes research policy. The areas that may have a major impact on future services are specifieddevelopment and evaluation of education and information for patients; need for specialist research directed towards the quality of life for diabetic patients; development and cost implications of new treatments such as glucose sensors, beta-cell transplantation, and immunomodulation or prevention of IDDM; evaluation of experimental approaches to provision of care, including their relation to prevention of complications; establishing the true prevalence of NIDDM and evaluating screening programmes; and introducing methods of continuous monitoring for trends in diabetes. This last research objective is central to the fourth, and perhaps the most important, observation-the need for information. The group found that their efforts were severely hampered by lack of data. All of their work was based on ad hoc studies and hospital activity information that was known to be fragmentary, unreliable, and out of date. There is now an international consensus on desirable standards and outcomes for diabetes health care, but provision of adequate resources for health care programmes, ensuring the quality of care, and planning for demographic and technological pressures will require more than a set of uncontentious objectives. Operational decisions now and future planning should be guided by accurate data. Without such information further exercises, such as that carried out by the Dutch group, will be fruitless. Without information, all the charters, guidelines, standards, and statements of good intent will achieve little now or in the future for most diabetic patients because it will be impossible to
monitor whether
they are being implemented efficiently, effectively, and comprehensively. 1. Pracon Incorporated. Center for Economic Studies in Medicine. Direct and indirect costs of diabetes in the United States 1987. Alexandria, VA: American Diabetes Association, 1988. 2. Gerard K, Donaldson C, Maynard A. The cost of diabetes. Diab Med 1989; 6: 164-70. 3. Laing W, William R. Diabetes: a model for health care management. London: Office of Health Economics, 1989. 4. American Diabetes Association. Standards of medical care for patients with diabetes mellitus. Diab Care 1989; 12: 365-68. 5. WHO and IDF Europe. Diabetes mellitus in Europe: a problem at all ages in all countries. A model for prevention and self care. St Vincent, Italy, Oct 11-12, 1989. 6. The British Diabetic Association. What diabetics are to expect. Patients’ Charter. London: BDA, 1990. 7. Alberti KGMM, Gries FA. Management of non-insulin-dependent diabetes in Europe: a consensus view. Diab Med 1988; 5: 275-81. 8. World Health Organisation. Guidelines for the development of a national programme for diabetes mellitus: Geneva: WHO, 1991. 9. Steering Committee on Future Health Scenarios. Chronic diseases in the year 2005—scenarios on diabetes mellitus 1990-2005. Dordrecht: Kluwer, 1991.
Schizophrenia: the rocky inpatient care
road from
Schizophrenia illustrates its etymology as much in its course as in its presentation. Both are characterised by islands of normality surrounded by oceans of chaos, with bewildering variability between patients. Consequently, it is not surprising that comprehensive follow-up studies of the disorder are hard to mount and difficult to interpret.l Although detailed accounts of the course of symptoms such as those of Bland and Om2and of Bleulerare impressive, these researchers concerned themselves with selected groups of patients, so it is difficult to generalise from their observations. Larger studies have been done but
drop-out rates are unacceptably high.4 Johnstone and her colleaguess have attempted to remedy this deficiency in an ambitious study. They set out to follow up all patients with a diagnosis of schizophrenia defined according to the Feighner criteria and discharged over a period of ten years between 1975 and 1985 from Harrow, an outer London district. The investigators achieved a remarkable tracing rate of nearly 94% of the total sample of 532 patients. Each patient had an average of about five admissions to hospital during the study period, accounting for about 11 % of the total follow-up period of 10 years. At an extended followup in 1990, only 31 of the patients were inpatients. Johnstone et al noted considerable social impairment: fewer than 20% of patients were in full-time work at 10-year follow-up, and most patients had a constricted lifestyle and some social difficulties. 327 patients were interviewed and 98 (30%) had had contact with the police, but only 38 (12%) of them were convicted, mainly for minor driving offences and those against property. Many of these contacts had arisen because patients were unable to care for themselves or had behaved inappropriately in public places. Cognitive impairment was noted in many of the patients,
If the mixed economy is to continue, of degree equity between the sectors is essential, and health authorities have been urged to come clean about their responsibilities in this respect.8 Is community care a viable option? There comes a level of infirmity at which such care turns into
ernphasised.’ some
expensive community neglect.4 Many people over ninety years of age lead active and independent lives,9 and it has been argued that preventive medicine and increasing affluence will lead to a compression of morbidity and a reduction in end-of-life dependency.10 But the fact that the numbers of people in their eighties and nineties are rising inevitably means that there will be more irreversibly disabled and dependent individuals who are likely to spend longer periods of time requiring 24-hour support.11.12 The dwindling stock of extended-care beds and local authority residential home places leaves the health and social services departments exceedingly poorly equipped to face the "geriatric imperative" .13,14 Private long-term-care insurance has not been successful in the USA and there is no reason to suppose it would do any better in the UK.15 There is no doubt that we will continue to need long-term care, both for physical and for psychiatric dependency, and that it matters greatly-to patients and their carers and to primary-care teams and acute hospital services. The question of who will pay requires urgent attention. 1. Anon. Increased suffering for the elderly on the NHS. Guardian, Oct 10, 1991. 2. Coni NK. Alive and well: geriatric medicine in the UK in 1984. Health Policy 1985; 5: 173-81. 3. Philp I, Mutch WJ, Ballinger BR, Boyd L. A comparison of care in private nursing homes, geriatric and psychogeriatric hospitals. Int J Genatr Psychiatry 1991; 6: 253-58. 4. Optit LJ. Domiciliary care for the elderly sick—economy or neglect? Br Med J 1977; i: 30-33. 5. Henwood M, Jowell T, Wistow G. Briefing paper 12: all things come (to those who wait). Causes and consequences of the community care delays. London: King’s Fund, 1991. 6. Audit Commission. Making a reality of community care. London: HM Stationery Office, 1986. 7. Livesley B. Cost-benefit consideration in the treatment of elderly people. Drugs Aging 1991; 1: 249-53. 8. Health and Social Security Select Committees. The financing of private residential care and nursing home fees. London: HM Stationery Office, 1991. 9. Bury M, Holme A. Life after ninety. London: Routledge, 1991. 10. Fries JF. Aging, natural death and the compression of morbidity. N Engl J Med 1980; 303: 130-35. 11. Stout RW, Crawford V. Active life expectancy and terminal dependency: trends in long term geriatric care over 33 years. Lancet 1988; i: 281-83. 12. Brody JA. Prospects for an ageing population. Nature 1985; 315: 463-66. 13. Laing W, Hall M. Agenda for health 1991: the challenges of ageing. London: Association of British Pharmaceutical Industries, 1991. 14. Anon. Discontinuing care. London: Age Concern, 1991. 15. Driver D. Successful ageing. The Times, Nov 4, 1991.
Diabetes practice: the information gap For those whose clinical practice includes a substantial proportion of diabetic patients the workload seems to increase inexorably without a concomitant change in resources. Yet we are told that
developed countries diabetic patients may be responsible for 4-5 % of national health care expenditure.1-3 So is the impression illusory? Is it merely that there has been a huge change in diabetes care during the past decade-eg, with respect to blood sugar monitoring, diet, intensified insulin therapy, treatment of complications, diabetes specialist nurses, patient education, management of diabetic pregnancy, and organisation of diabetes care? Perhaps it is a consequence of the scramble to keep ahead of the startling proliferation of charters, guidelines, and consensus statements.4-8 Or maybe there is an increasing mismatch between expectations and in
The truth is that most of us have not the faintest idea because we spend all our time reacting to a rapidly and unpredictably changing world. We seldom take even a few moments to consider whether we are doing what we should be doing now, far less ponder the future. This pattern is equally true for funding agencies. Such a passive approach is unlikely to achieve the best use of available resources. A report commissioned in 1988 by the Dutch Government attempts to address many of these issues.9 Discussion of the views of health care professionals on organisation and outcome of diabetes health care is mostly unexceptional, reflecting existing knowledge and opinion on best practice. Quality of life, which is often overlooked in chronic disease management, is’identified as a key focus for services, in addition to traditional medical outcomes such as blindness and amputation. Disappointingly, however, no patients’ views were sought. Diabetic patients are knowledgeable consumers who are in lifelong contact with the services provided for them; their opinions are important for policy developments. Diabetes in pregnancy is also largely ignored. Nevertheless, four key points emerge that are of general relevance to the future provision of diabetes care. First, there is a need for government policies with respect to diabetes mellitus. The Dutch are probably entirely representative in having none. The report suggests that central policy objectives should include measures that lead to increased self-care and early detection of complications. Diabetes specialist nurses, better patient education and information facilities, community-based dieticians, regular clinic review for evaluation of metabolic control, and early detection of complications and extra training of medical and paramedical health care professionals are given as examples of proven systems. This conclusion is entirely consistent with all the existing charters, consensus documents, protocols, &c. Nevertheless, central support is essential if patchy practice is to be made more consistent. Second, the report identifies the likelihood of a very considerable increase in the number of diabetic patients during the next fifteen years. Calculations were based on the reasonable assumption that the incidence of insulin-dependent diabetes mellitus (IDDM) would continue to increase slowly in young resources.
98
people and that, within the time-frame considered (1990-2005), public health/health education measures would be unlikely to alter the prevalence of obesity appreciably. Existing and expected demographic changes then imply that in the Netherlands there will be a slight increase in IDDM and a large increase in non-insulin dependent diabetes (NIDDM); overall, the increase could be as much as 40% (or 75% compared with 1980), the largest changes occurring in the 45-65 and over-80 age groups. Overall prevalence would then be about 2 % of the population, about 33 % of whom would be treated with diet alone, 44% with tablets, and 23% with insulin. Organising services for the care of patients with diabetes involves many people and agencies--eg, hospital-based and primary care diabetes teams, community services, patients themselves, with whom responsibility for much day-to-day management rests, and the general population among whom they live and work. Such large numerical changes will have appreciable effects on all these groups. Projections for other developed countries are likely to resemble the Dutch calculations; for developing countries, in which life expectancy is still increasing rapidly, they may be even more striking. Third, the report identifies the need to develop a diabetes research policy. The areas that may have a major impact on future services are specifieddevelopment and evaluation of education and information for patients; need for specialist research directed towards the quality of life for diabetic patients; development and cost implications of new treatments such as glucose sensors, beta-cell transplantation, and immunomodulation or prevention of IDDM; evaluation of experimental approaches to provision of care, including their relation to prevention of complications; establishing the true prevalence of NIDDM and evaluating screening programmes; and introducing methods of continuous monitoring for trends in diabetes. This last research objective is central to the fourth, and perhaps the most important, observation-the need for information. The group found that their efforts were severely hampered by lack of data. All of their work was based on ad hoc studies and hospital activity information that was known to be fragmentary, unreliable, and out of date. There is now an international consensus on desirable standards and outcomes for diabetes health care, but provision of adequate resources for health care programmes, ensuring the quality of care, and planning for demographic and technological pressures will require more than a set of uncontentious objectives. Operational decisions now and future planning should be guided by accurate data. Without such information further exercises, such as that carried out by the Dutch group, will be fruitless. Without information, all the charters, guidelines, standards, and statements of good intent will achieve little now or in the future for most diabetic patients because it will be impossible to
monitor whether
they are being implemented efficiently, effectively, and comprehensively. 1. Pracon Incorporated. Center for Economic Studies in Medicine. Direct and indirect costs of diabetes in the United States 1987. Alexandria, VA: American Diabetes Association, 1988. 2. Gerard K, Donaldson C, Maynard A. The cost of diabetes. Diab Med 1989; 6: 164-70. 3. Laing W, William R. Diabetes: a model for health care management. London: Office of Health Economics, 1989. 4. American Diabetes Association. Standards of medical care for patients with diabetes mellitus. Diab Care 1989; 12: 365-68. 5. WHO and IDF Europe. Diabetes mellitus in Europe: a problem at all ages in all countries. A model for prevention and self care. St Vincent, Italy, Oct 11-12, 1989. 6. The British Diabetic Association. What diabetics are to expect. Patients’ Charter. London: BDA, 1990. 7. Alberti KGMM, Gries FA. Management of non-insulin-dependent diabetes in Europe: a consensus view. Diab Med 1988; 5: 275-81. 8. World Health Organisation. Guidelines for the development of a national programme for diabetes mellitus: Geneva: WHO, 1991. 9. Steering Committee on Future Health Scenarios. Chronic diseases in the year 2005—scenarios on diabetes mellitus 1990-2005. Dordrecht: Kluwer, 1991.
Schizophrenia: the rocky inpatient care
road from
Schizophrenia illustrates its etymology as much in its course as in its presentation. Both are characterised by islands of normality surrounded by oceans of chaos, with bewildering variability between patients. Consequently, it is not surprising that comprehensive follow-up studies of the disorder are hard to mount and difficult to interpret.l Although detailed accounts of the course of symptoms such as those of Bland and Om2and of Bleulerare impressive, these researchers concerned themselves with selected groups of patients, so it is difficult to generalise from their observations. Larger studies have been done but
drop-out rates are unacceptably high.4 Johnstone and her colleaguess have attempted to remedy this deficiency in an ambitious study. They set out to follow up all patients with a diagnosis of schizophrenia defined according to the Feighner criteria and discharged over a period of ten years between 1975 and 1985 from Harrow, an outer London district. The investigators achieved a remarkable tracing rate of nearly 94% of the total sample of 532 patients. Each patient had an average of about five admissions to hospital during the study period, accounting for about 11 % of the total follow-up period of 10 years. At an extended followup in 1990, only 31 of the patients were inpatients. Johnstone et al noted considerable social impairment: fewer than 20% of patients were in full-time work at 10-year follow-up, and most patients had a constricted lifestyle and some social difficulties. 327 patients were interviewed and 98 (30%) had had contact with the police, but only 38 (12%) of them were convicted, mainly for minor driving offences and those against property. Many of these contacts had arisen because patients were unable to care for themselves or had behaved inappropriately in public places. Cognitive impairment was noted in many of the patients,
