Getting better ...

… it’s getting better all the time (the Beatles 1967). The lyric popped into my head reading the most recent Commonwealth Fund report – the 2011 International Health Policy Survey of Sicker Adults in Eleven Countries. Although Paul McCartney wrote this song walking his dog and watching the sunrise, I think I may have had the lyric in my mind because I recently watched Martin Scorsese’s biopic “ living in a material world” on the life of George Harrison.

The Commonwealth Fund have sampled patients from a range of countries including a thousand patients from the United Kingdom; 62% of patients were 50 years or older and nearly 50% had two or more chronic conditions, had been hospitalised in the last year and over a third were taking more than four prescription drugs. They looked at a range of core topics including affordability and access to care, care coordination and care transitions, patient safety, patient centred care, doctor/patient relationships and patient activation, managing chronic conditions, medical homes and United States experiences by age and insurance status.

Spending per capita of the population now represents 9.8% of UK Gross Domestic Product (GDP) which is greater than Australia and New Zealand, lags behind other European countries and is dwarfed by the USA expenditure of $7960 per person which represents 17.4% of the GDP.

The comparisons make interesting reading. It’s reassuring to see that only 1% of people in the UK had a serious problem in paying medical bills, having to spend more than the equivalent of $1000 US on out of pocket expenses. This compares to 27% of the US population having difficulty paying bills and 39% of Australians who fit the profile having more than the equivalent of $1000 out of pocket expenses. The UK was also better than most countries at the ability of patients to be seen the same or the next day when needed and in getting out of hours care. We were in the top half in waiting time to see a specialist, there were fewer co-ordination gaps in care and, 84% of patients reported having their medicines reviewed with a pharmacist or a doctor within the past year. In the UK 79% reported a positive shared decision making experience with specialists where they were given opportunities to ask questions about recommended treatments, were told about their treatment choices and involved as much as they wanted to be in decisions about care.

Nearly 70% of people in the UK responded “yes” to the three questions “ in the past year has a health professional discussed your main goals and priorities with you ?”, “ …..helped make a treatment plan you could carry out in daily life?” and “ …..given clear instructions on symptoms and when to seek care?”. Switzerland ran us close scoring 67%

We weren’t top the league at everything. For people with heart disease, hypertension and/or diabetes, only 69% of people reported their blood pressure was under control last time it was checked which is the lowest of all the countries and compared unfavourably to Canada, Norway and the USA where 85% of patients had good BP control.

People who reported that they regularly saw the same doctor , who is accessible, knows you and helps coordinate your care scored much higher on doctor/patient relationships and communication, had fewer coordination gaps in their care and were more engaged. With the increase in the number of kidney doctors in many units over the last 10 years some of the personal touch and continuity has been lost and “seeing different doctors every time “ is one of the frequent comments I hear when I go secret shopping . Most of the people in the UK who had good coordination of care reported services were excellent or very good (88%) versus only 60% who considered their access to care restricted or who felt coordination was inadequately for their needs.

How do these great scores fit with the relatively low levels of patient activation reported from earlier studies of CKD where relatively low levels of engagement were usually found across a broad range of measures? The answer may be found in the precise questions asked or in the selective nature of the sicker adult group studied by the Commonwealth Fund. It may be that the questions need refining. My anecdotal experience chatting to a range of people to probe this question is that those with long term conditions rarely discuss their goals with clinicians – they usually discuss goals they think the clinician wants to talk about and usually these are clinical biometric goals. So although we are doing better than most countries and we should be proud of that I think there is still some way to go in providing coordinated holistic patient centred care.