Richard Smith: UN meeting on NCDs – day two

Richard SmithTuesday 20 September. Day two
7.10 Traffic is gridlocked near the UN building because so many streets are shut. Obama hits the UN today—not unfortunately the NCD meeting.

7.35 I arrive at the UK Mission to the UN. “I work in the mission,” a woman tells me, “I know it sounds silly.” I can’t stop myself singing “Will you come to the mission, will you come?” The woman from the mission negotiated the NCD declaration on behalf of the UK government and said that she was surprised that it was more controversial than the AIDS declaration. The arguments were over targets, resources, and TRIPS.
I say that I’m taken aback by the UN process. “So was I when I arrived,” she says. “If you want fast results don’t go in for diplomacy. This is a glacial game. But things do change. We’re debating women’s rights in a way that was impossible 20 years ago and gay rights in a way that was impossible five years ago. I love that the Sudan must talk on what it’s doing about women’s rights in the same meeting as Norway, and I love Robert Mugabe talking about what he’s doing about NCDs. Everybody in the room knows he’s lying.”

8.00 The side meeting on patient empowerment sponsored by BUPA and the George Institute begins. Patient empowerment is not a nice to have it’s a must have, says Anne-Marie Feyer of the George Institute. We need to build it into health system, operationalise it. She is launching a report on patient empowerment and NCDs.

8.10 Real patient empowerment can improve quality and cut costs, says David Wennberg from Bupa. A study in Health Affairs of patients who had undergone nine common procedures—like hip replacement—showed that they hadn’t received half of the information they should have received. “It’s really embarrassing,” says Wennberg, “but many patients don’t know that they have a choice. They think that they just have to do what the doctor says.” An RCT of 170 000 patients published in the New England Journal of Medicine in September showed that patients intensely supported with decision aids had 10% fewer admissions to hospital and costs that were 3.5% lower.

8.15 Rushika Fernandapulle of IORA Health reminds us that patients with NCDs spend two hours a year with health professionals and  8758 hours (more in a leap year) without. Of course they have to be in charge. He describes how his company redesigned the health system for casino workers in Atlantic City to make patient empowerment central. All patients have a personal health provider who comes from their community and advises them on all choices. Technology and data analysis underpin the redesigned system. The result was an increase in primary care and drug costs (because patients took their drugs) but hospital admissions went down by 40% and costs by 15%. (Are these results possible only in an excessive health care system like the US, I ask later. The point is not necessarily to cut costs but to empower patients because it’s the right thing to do and to get more benefits from the system, says Feyer.

8.20 I’ve hardly heard patients mentioned at the NCD meeting, said Eva Maria Lopez from the International Alliance of Patients Organisations.

8.50 “We tried to get patient empowerment into the UN declaration but the developing countries didn’t want it,” says the woman from the mission.

8.55 A doctor tells us that medical students at Georgetown University have to make a personal change—lose weight or stop smoking. They find it hard.

9.10 I hear that the NCD meeting has bee extended by two hours because 136 countries want to speak. And the meeting has evidently been attended by some 34 heads of state, more than for the AIDS meeting.

9.30 The BUPA meeting ends after the usual confused but occasionally interesting conversation. The conclusion is “Don’t just talk about patient empowerment. Start doing, experimenting, evaluating, and making changes as necessary.”

9.35 That’s the end of the UN meeting for me. I have no tickets for today, and I’m certainly not going to watch the webcast. Has it been a success? The meeting itself, I now understand, is a ritual. The horse trading went on before the meeting, and the declaration has something for everybody—too much, I’d say. There may be no targets, but could we set realistic targets at this stage when global surveillance data are so weak? The now familiar phrase of “all of government and all of society” is a good one that has helped people understand that a response from only the health system will be hopeless. There is a proposal for creating a global plan, and it’s more realistic to do it over the next year or two than to have thrown it together in the past year. Consciousness has been raised, new data have been released, and one of the biggest benefits has been the creation of the NCD Alliance, which now has 2000 members.
The big failures for me have been the failure to raise understanding of NCDs among the wider population and—as discussed at this morning’s meeting—the failure to recognise the need for a system that has at its centre patients not professionals.

Richard Smith was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.