Table Of ContentChronic Disease Management:
A New Paradigm for Care
PATRICK J MCEVOY
FRCGP
General Medical Practitioner
Londonderry
Foreword by
PROFESSOR MIKE PRINGLE
President
Royal College of General Practitioners
Radcliff e Publishing
London • New York
CRC Press
Taylor & Francis Group
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© 2014 by Patrick J McEvoy
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Contents
Foreword vii
About the author viii
Acknowledgements ix
Introduction: chronic disease, its natural history and
ecology 1
But, is it possible to get excited about chronic disease? 3
Suggestions for using this book 4
So, what’s on offer? 4
References 5
1 Chronic disease: what’s so special about it? 6
Chapter overview: executive summary 6
Chronic disease management in a nutshell 8
Are you interested in chronic disease? 12
How many chronic diseases do you have? 13
Scenario: a consultation 17
The impact of chronic disease 18
Some characteristics of chronic disease 23
Disability as a chronic condition 31
Scenario: tutorial time 32
Conclusion and refl ection 35
References 36
2 The story of chronic disease (the disease complex) 38
Chapter overview 38
Scenario: story time 39
Chronic disease, the enemy within 40
Profi ling chronic disease: chronic versus acute disease 42
The natural history of chronic disease: the life cycle of the Dragon 44
Models of disease 47
Co- morbidity and multi- morbidity 51
The ecology of the Dragon 52
Entering the Dragon’s den 54
Laying the foundation stone of the chronic disease paradigm 65
Summary: the story to date 66
A bit of epidemiology 67
Conclusion and refl ection 77
References 78
iii
iv CONTENTS
3 The journey through chronic disease
(the patient complex) 80
Chapter overview 80
What is it like to live with chronic disease? 81
Scenario: a case study 82
The patient’s journey through chronic disease 86
The early days: the importance of diagnosis 88
The middle passage: illness progression and transitions 95
Advanced disease: the palliative phase and end of life 99
The clinician’s journey with the patient 101
The sociology of health and disease 104
The healer role 114
The social determinants of health and disease 119
Scenario: a refl ective learning diary – patients, their carers and advocates 126
Conclusion and refl ection 129
References 130
4 Care of the chronic sick: the community complex 134
Chapter overview 134
Who cares? 135
Scenario: the village 136
Care in the community 139
Levels of care: how much, who cares, where and at what cost? 140
Issues in care: autonomy, advocacy and agency 151
The expert patient and self-m anagement 152
The caring professions 156
A historical note on UK systems of health and social care 158
Scenario: a practice policy on carers 159
Conclusion and refl ection 161
References 162
5 The clinical complex: the general practitioner and
chronic care 164
Chapter overview 164
Part One: general practice as the focus of chronic disease
management 165
What GPs do: fi shing or fi ltering? 167
General practice: concept and method 171
Scenario: a multidisciplinary learning exercise 182
Designated clinics in general practice 183
Health promotion and health education 188
Scenario: a review of progress with our once new trainee 191
Part Two: developing the clinical complex 192
Electronic media and general practice 192
Internet interventions and patient self-h elp 196
CONTENTS v
Integrated care 197
Commissioning chronic care 203
The quality agenda 205
Management and governance 216
Evidence, guidelines and audit 218
Conclusion and refl ection 225
References 226
6 A chronic care revolution: service redesign and the
policy complex 230
Chapter overview 230
Health policy for long- term conditions: global, national
and local 231
WHO policy and chronic disease management 234
Unpacking health policy 237
Building blocks of the chronic care revolution 243
Scenario: a coffee break 251
Ten characteristics of an effective health service 252
The four strategies 261
Social policy and chronic care 264
A 12- step rehabilitation programme for health systems 265
Conclusion and refl ection 266
References 267
7 The learning and teaching complex through the
chronic disease paradigm 270
Chapter overview 270
Medical education in primary care: a UK profi le 271
How is chronic care taught? 273
The chronic disease paradigm 276
The chronic disease paradigm unpacked 278
Chronic illness care: a summary for students and trainees 289
Chronic illness care: a new specialism 292
Scenario: Refl ections of a trainer – learning through chronic disease 296
Conclusion and refl ection 301
References 301
8 Meeting the challenges of chronic care 303
Chapter overview 303
We have a problem on our hands! 304
The National Health Service is well placed 306
Is general practice meeting the challenge of chronic disease? 307
A menu of tactical responses 310
Taking stock of UK primary care 311
Slimming practice, weight reduction and noise abatement 314
Chronic care guidelines for the general practitioner 319
vi CONTENTS
Conclusion 321
References 323
Appendix 1: A simple integrated chronic disease management paradigm 325
Appendix 2: The trajectory model of chronic disease 327
Appendix 3: Modifi ed pyramid of levels of care 328
Index 329
Foreword
In the next 20 years, the Department of Health in England expects the number of
those aged over 80 years to double and the number of people with a long-t erm con-
dition to increase by 3 million. Th e same trends apply in all developed countries.
While there is nothing we can do to alter these facts, there is much we can do to
address the way we conceive of and manage chronic disease.
As this book sets out, health systems have been trying to squeeze the manage-
ment of chronic disease into an acute care mould. Furthermore, it is perverse that
chronic disease represents so much loss of quality of life for patients, so much work
for primary care teams, so much resource use in our hospitals, yet we do not place
proportionate weight on understanding, training for and planning chronic care.
Long-t erm conditions along with multi-m orbidity will be the priority challenge
for this century in all health systems, and we need fresh thinking and new tools to
confront this challenge.
Our major resource is, of course, those with chronic diseases themselves. Th ey
are the experts on their experience of the illness and care pathway, on their expec-
tations and on the trade-o ff s that they will fi nd acceptable. At the same time, health
professionals are the custodians of scientifi c information and service resources. Th e
best decision-m aking comes when the consultation is a meeting of the two experts,
both striving from diff erent perspectives to achieve the same overall goals of eff ective
care and maximum well- being along the continuing path of illness and disability.
For those who aspire to achieve optimal outcomes, this book is their invaluable
guide. It presents an evidence- based, generic profi le of chronic disease as well as
putting a recognisable face on the main players – the patients, their carers, the clin-
icians, all involved in training and the health system. Th ree key elements emerge:
(1) a generic paradigm of chronic disease, (2) a trajectory- based model of clinical
management and (3) a curriculum for chronic care. Th ese have universal applica-
tion. Dr McEvoy, who has written extensively on medical education, presents us
with a timely analysis of current issues in chronic disease as well as a unique teach-
ing and learning resource.
Professor Mike Pringle
President
Royal College of General Practitioners
March 2014
vii
About the author
Patrick J McEvoy was born in Larne, Northern Ireland, in 1947 and was educated at
St MacNissi’s College and Th e Queen’s University of Belfast. He graduated in medi-
cine in 1971 and was made Fellow of the Royal College of General Practitioners in
1994. From 2000 to 2002 he was Provost, Royal College of General Practitioners
Northern Ireland.
Following hospital posts in Belfast and Kenya, he worked in general practices
in Belfast before taking up partnership at Th e Aberfoyle Medical Practice, Derry,
in 1978. He was also Honorary Lecturer at the Faculty of Medicine, Th e Queen’s
University of Belfast, 1998–2012; Trainer and Programme Director with the
Northern Ireland Medical and Dental Training Agency, 1982–2008; and Chair of
the Association of Course Organisers, 2005.
He is the author of the UK training manual for GP postgraduate programme
directors, Educating the Future GP: Th e Course Organisers’ Handbook (1993; 2nd
edition 1998), published by Radcliff e Medical Press.
Between 1994 and 2006 he undertook medical educational consultancies in
Slovakia, Romania and Egypt.
He is married to Hazel, who is a counsellor, and they have four children and fi ve
grandchildren. His interests include music, choral singing, poetry, history, country-
side walks and leisurely swimming.
viii
Acknowledgements
I gratefully acknowledge the supportive assistance of my wife, Dr Hazel McEvoy,
for her constant encouragement, suggestions, logistic support and her forbearance
during my absence while writing; my sons Mark, for IT support and suggestions,
and John, for aspects of healthcare in the United States; my daughters Siobhan, for
insights into multidisciplinary work, and Frances, for comments on mental health.
In the development of the book, Dr Paul Sackin provided invaluable formative guid-
ance at all stages. Dr Kathleen Dunne, Professor Hugh McGavock and Professor
Philip Reilly helped greatly by reading and commenting on the full text. Th anks are
also due to all my former medical colleagues at Th e Aberfoyle Medical Practice, who
willingly agreed to read and comment on various chapters; special thanks to Shane
Cunning for computer assistance. Th e staff at Radcliff e Publishing have been unfail-
ingly supportive in the production of this book. I am grateful to the late Dr Peter
Fallon, and to all who taught me medicine. I also owe a debt of gratitude to all my
trainees, from whom I have learned so much.
Th e Association of Course Organisers, sadly no longer in existence, was the col-
lective voice of programme directors for general practice training in the UK from
1985 until it was wound up in 2010. I owe a great deal to its founders and members
over the years. Th eir supportive infl uence through annual conferences and other
meetings made me, in as far as I am, a teacher and a writer. I wish to pay tribute
here to the Association of Course Organisers and its fundamental contribution to
GP training in these islands over 25 years, with gratitude for all of the people who
contributed to its successes.
ix
