This week’s podcast features Dr. Mohan-pal Singh Chandan, a GP working within the NHS who we met at the Prescribing Lifestyle Medicine Conference this year.
Dr. Chandan has garnered government support to start up a community-based lifestyle medicine clinic in a poor area of inner city Birmingham, UK.
By supporting lifestyle interventions and incentivizing peer-to-peer medicine, they’ve not only seen a dramatic reduction in medical visits and pharmaceutical use, but also remissions of so-called chronic conditions throughout their pilot program.
Tune in today to see the dramatic power of lifestyle community interventions for improving patient outcomes, including:
- How Dr. Chandan convinced his employer to fund this pilot program
- A summary of pilot program data, like how patient empowerment led to a 20% reduction in GP visits, a 10% reduction in prescription costs and a variety of positive health outcomes for Birmingham residents
- Dr. Chandan‘s favorite structures for facilitating successful peer-to-peer medicine
- The special role faith-based communities play in community-based healthcare, and how those qualities can translate to any community
- Details on how we plan to use kNew Health Cooperative to bring medicine back into communities, re-empower patients and achieve these same types of results in the United States
This impressive data from Dr. Chandan’s pilot program offers further proof that community-based health incentives and peer-to-peer support are the ultimate creators of good health.
Learn how it’s done (and how we plan to do it with kNew Health) by listening and subscribing to the podcast today.
Resources mentioned in this podcast: The kNew Health Cooperative
Announcer: Welcome to the Evolution of Medicine podcast. The place health professionals come to hear from innovators and agitators leading the charge. We cover the latest clinical breakthroughs in health technology as well as practical tools to help transform your practice and the health of your community. Now here’s your host James Maskell.
James Maskell: Hello and welcome to the podcast. This week we feature Dr. Mohan-Pal Singh Chandan. He is an NHS GP, general practitioner, who for the last year has been doing an experiment in community, bringing in community structures to his local practice and using lifestyle interventions to be able to see what the impact would be on things like usage of doctors and pharma spend or whatever. It was a really incredible half an hour because it speaks to exactly what we’re trying to do with the new health co-operative which is to realign incentives to have people help each other. I think what you’re going to see today is the dramatic power of lifestyle interventions to change health costs and health outcomes. Then we’re going to go one step further than that and we’re going to look at the way in which we can actually facilitate this through the new health co-operative. It’s a really amazing half an hour. Enjoy!
So a warm welcome to the podcast Dr. Mohan-Pal Singh Chandan. Welcome Doc.
Dr. M. Chandan: Hi. How are you?
James Maskell: Great. Great to have you here on the podcast and excited to share. Obviously since we’ve announced the idea for that health co-operative, we’ve really been on a march to talk about the real power of community in medicine. When we had a chance to meet back at Dr. Chatterjee’s course back in January it sounded like you’d be doing some really interesting things on the cross section of community in medicine. So why don’t we just jump right in. Can you share with the audience just a little bit about your background and how you got interested in delivering community medicine?
Dr. M. Chandan: Absolutely. Absolutely. So I mean I’m a GP, so a family physician. I qualified a couple of years ago. Actually from very early on in my medical career I’ve been quite disaffected by some aspects of clinical care that we provide. I feel that while you and I live in very developed countries with some of the … arguably some of the best health systems in the whole world, there is still lots of room for improvement. There is still a lot of downsides to the way healthcare has turned over over the last maybe 20 to 30 years.
One example is that actually I really feel that we are quite quick to prescribe pills to ameliorate issues when actually the pill doesn’t treat the root cause of the illness. It doesn’t treat the root cause of the problem which can be physical, it can be nutritional, it can be social. So these are the kinds of things that we tend to … have difficulty managing in our healthcare systems.
So that was a problem that sort of … that really got to me. Then as I’ve practiced more in community medicine, in family practice in the UK … which is absolutely fantastic as a career. This feeling of being disaffected with “the pill for every ill” model has only gotten stronger and stronger. So when I qualified I said to my employer at the time … I said, “Listen, maybe there’s something we can do better. Maybe we could try to open a clinic or demonstrate the proof of the concept that actually we can provide medical care with fewer prescriptions and actually more emphasis on tackling lifestyle factors, tackling root cause factors and actually building community.”
The interesting thing to say here is that I was in the right place at the right time because locally we also have a very strong community organization. It’s actually a faith based community who are very, very active in the area of inner city Birmingham where I work and live who were very keen to see what they could do to prevent illness and give back to the community where they are sited.
So we had really all the stars align. We had a community that was ready to go with this. We had a healthcare provider, a community healthcare provider who was keen on the idea. So we set up a little clinic. It’s run for 12 months and it’s been absolutely fantastic, James. We’ve proven the concept that actually there is more to be gained from primary care, from family medicine than what we are currently providing.
There is actually room for general practitioners, family physicians to be an active advocate for patients to address lifestyle factors that are causing or contributing to their diseases. So we’ve proven that addressing lifestyle factors is everyone’s job really. I don’t know how it is over in the States but on this side of the Atlantic, James, we often have health coaches or health trainers who are fantastic at coaching patients and getting patients to help change their behaviors.
But one of the problems that we have in our whole system is that actually there are a lot of deflections for a patient. A patient will go to their general practitioner and then be deflected to another surface and deflected onwards and onwards into a hospital or into another community setting. So my feeling is that actually the more we deflect people the worse our doctor-patient relationship can be. Actually that’s a really important part of care.
So what we’ve proven this year is that actually there’s a lot to be gained from lifestyle medicine. I know that you are very well aware of that. I’m really excited about what you guys are doing.
James Maskell: Yeah. So just tell us a little bit. You said you’ve quantified it and proved it. I know it was a pilot program that you were funded for. Can you talk us through some of the results of the pilot?
Dr. M. Chandan: Absolutely. So James, we … One of the things we were really keen to do from the outset is that if we’re going to do anything we need to be measuring it properly and see the outcome of it ideally to really build a business case to stimulate the project continuing or other projects similar to this in other parts of the country. James, I mean, with the big picture I really see that this is the future of healthcare. That actually we’ve been, I guess for 50 years now, prescribing increasingly expensive treatments, second and third line and fourth line agents for multiple conditions. In many ways they’re helping but in many ways they’re not getting to the bottom of the problem. So I really feel this is the way the tide is turning. So we try in our humble way to contribute to that.
We managed to collect quite a bit of data. I’ll just summarize that for you now, James, in just a couple of points. One of the things we found first of all was that if we gave patients an opportunity to be empowered and feel that they’re back in control of their health again, they’re back in control of their life again really. James, once people are empowered and they’re motivated and they’re geared up to go then they don’t need to see their own GP that much.
Anyway that was the theory. Actually that’s been going out in the figures because we’ve seen that patients who attended this clinic even just once for a one-off appointment discussing lifestyle factors and discussing taking control of your health had 20% reduction in their GP appointments after that point. So far we’ve got data to about nine months. That affect seems to be sustained. So even nine months after a one-off appointment about lifestyle medicine, they are 20% less likely to consult their primary care physician which is fantastic for them. It’s also fantastic for the healthcare provider. You’re talking a 20% reduction in the … your appointment burden which is great for them.
We have also seen a reduction in prescribing costs. So to the tune of around about 10% over the whole population that we’ve seen. So that’s a 10% reduction in their monthly costs of all the prescriptions that’s given by their GP which is massive. If this was on a population scale that would be an absolutely huge saving for a healthcare provider.
Obviously in the UK we have the NHS. We have a national system. We don’t have medical insurance but actually regardless of the healthcare system more efficient prescribing is in everyone’s interest whether you’re paying insurance or whether you’re paying tax to fund the NHS. So that was really fantastic.
One of the things that really actually motivated me most when we’re looking at our data is actually impact on actual health outcomes. So James, for a lot of the patients actually who are … had high weight issues, they wanted to lose weight, they had obesity or they had obesity related problems. So they’re having diabetes or they’re having knee pain or they’re having other kind of long term chronic diseases which are very difficult to really tackle. We found that just by giving them one appointment where we made a lifestyle medicine plan for them led to them losing an average of around about two and a half kilograms. So we’re looking at it seems to be statistically significant. But that’s just the average. Obviously there were some people that gained weight up to even a couple of people have actually gained quite a lot of weight. But actually there’s a whole bunch of people who gained one stone here, two stone, three stone. So some people have done fantastically well.
Then probably the last point when it comes to hard data number crunching is actually the impact that this single appointment has had on diabetes. So James, for the patients who are diabetic and attended this clinic the vast majority of them actually had a … saw a massive improvement in their diabetes. We’re talking an average of an 8.6 points reduction in HbA1C for those who understand the numbers. But that to break it back down into English is a real fantastic improvement in their diabetes control. We have had six patients who’ve … they’re there or they’re nearly there in terms of getting their diabetes into remission. Diabetes is not a disease that we could say is effectively cured because cure implies that it will never come back. But you can say the word remission. So we’ve got six patients who are at or near remission from being on diabetes with tablets or even with insulin injections. So that’s been fantastic.
Then the biggest one for the patients … and this is the last point about data is actually … James, before they have their appointment we gave them a little questionnaire to fill in which is about how healthy and how well do they actually feel in themselves. Then we called them up about maybe three or four months later after that one appointment and we noticed a massive jump in the way they feel. A massive improvement in how well they feel. That’s three or four months after a single appointment which for me was really, really motivating because we were doing this on a budget. Actually we’re just offering patients just one appointment in the service. They can have some group follow-up if they wanted to but we’ve seen that just from one appointment they’re feeling better in themselves. Their health is actually better. They’re going to the GP less. They’re using less prescribed treatments.
These are all really good things. So what we’ve managed to do hopefully is prove the concept in a very difficult, inner city area within the UK, within the NHS, the National Health Service. That actually lifestyle medicine has a role and there’s a chance here for some significant benefit for people and for the whole health system.
James Maskell: Yeah. Absolutely. That was the kind of data that really stuck with me when we spoke because ultimately I’m super interested in facilitating this kind of transformation at a large scale like initially in America because there’s just an unlimited appetite for it because we’ve got so many people who are on medication. We got so many people who are type 2 diabetic. We have so many people with heart disease. We have so many people with auto-immune disease. So ultimately the whole point of what we’re looking to do is kNew. So I appreciate you sharing that.
One of the things … I guess what I’d like to say is that this is not abnormal. Right? You see the results from when the Blue Zone ideas which were brought back to a city in Minnesota. They reduced healthcare costs by 41%. I know in Frome and Somerset they’ve shown significant gains from these community based initiatives.
So I guess what I wanted to take the conversation in more of a direction is that this has proven to … In other words, I’ve got enough evidence for me to move forward with this. That we’re going to do it. To deliver the lifestyle recommendations and coaching through a digital platform to reduce the cost and increase the accessibility particularly in areas where people are relying on public transport and that kind of thing. So doing the majority of it through … and delivering that using other practitioners that can do it at a lower cost. Then ultimately the goal being to achieve the same kind of results that you’re seeing.
But I guess inside the NHS … The NHS is really kind of like one big health cost sharing co-operative, if you will, because it’s like a country or society.
Dr. M. Chandan: Absolutely.
James Maskell: They’re going to reduce … They’re going to work to share the costs. But ultimately the individual people there … they probably want to do good by their community to a certain degree. How much of a role do you think the sort of desire to get people well and help people well … How much do you think that is fostered inside the NHS system?
Dr. M. Chandan: James, put it this way. When I was a kid I said I want to help people. Then I ended up becoming a doctor. People go into this profession out of a desire for benevolence, out of a desire to help people with their health. So I think that’s an absolutely massive part of the reason why individuals come into this profession. But then I think also as an organization I think the NHS really, really does foster that. I mean I can’t necessarily speak for other places where I have not worked. But certainly wherever I’ve worked, James, within the NHS I think patient care and compassion has always been at the outset. I mean why is it James that so many people within healthcare organizations are working overtime, unpaid. Why are people going that extra mile? It’s because people have a genuine, deep desire to help people who are in need.
So I think to bring this onto your point about community. I think we are a national community. We are a local community. Even a family could be considered a community. Actually helping each other improve is going to improve the other person’s life and it’s going to improve your life as well. So that spirit of benevolence, care and compassion that really runs through everything that we do.
James Maskell: Absolutely. Have you seen any structures that you like to be able to facilitate peer to peer interaction? Because ultimately that’s where I feel like … from what we’ve seen from things in addiction and chronic disease, the person that has reversed their own type 2 diabetes … if you get people with type 2 diabetes in a room together and you’re facilitating a conversation as the doctor and there’s also someone in that room who has reversed their own type 2 diabetes with these structures, who’s the most credible person in that room? Who has the biggest sway for the other people? It’s typically not the doctor.
Dr. M. Chandan: Absolutely.
James Maskell: It’s the other person. Right? Have you found ways to be able to engage that structure in what you’re doing?
Dr. M. Chandan: Absolutely. We’ve seen that in formal ways and informal ways. So formal things that we’ve done is actually for patients who have been seen in this clinic we offer them group follow up. That has been so powerful because we’ve got other patients then telling each other what they’ve done. One lady’s cut out ginger beer and another lady’s figured out a really cool way of getting in her vegetables. So they inspire each other, bounce off each other in ways that are so much more effective than anything that a healthcare professional could do. I think they say it with such credibility.
One little anecdote I’ll share with you is that … We had a lady who’s recently suffered really bad bereavement, really bad loss. Yeah. Bereavement and loss is some of the most tragic and one of the most difficult things you can go through in your life. So she came to the group afterwards. Then there was another lady who had also experienced loss. Actually the way that she conveyed her experiences was so powerful and so emotive that actually that seemed to have a massive lasting impact on the first lady who had had that recent bereavement. Actually I think what she did for our patient in my view may well be far more effective than anything that I could do as a medical professional.
So we’ve seen that in formal ways but then the other thing that we have here in Handsworth, in Birmingham, is actually a very strong community spirit. Handsworth is a very small area of inner city Birmingham where we’ve got 170 nationalities represented. So it’s almost like the … I call it the United Nations. But this is a deprived area. I think there are elements to that that actually bring people together. So we’ve seen aspects of community forming quite organically without any formal structure and just by virtue of where we live and what happens.
The example of that is literally the local shops down the main road here. The shopkeepers are pillars of the community. These are people that are … People who have long term relationship with … We’re operating next to a pharmacy. The pharmacists are also … they’ve got such a great working relationship with some of the patients that come there. So it becomes like a community hub. It’s a beautiful thing. I think community happens where there is genuine care, compassion and trust. I think if you have trust in people and their organization and you know that they’re going to be compassionate towards you, you’ll go there and you’ll spend time there. I think you’ll gain therefore the benefits of community from a place.
James Maskell: Absolutely. What role did you say you mentioned earlier like a faith based situation? If you look at the Blue Zones it’s not the whole of Loma Linda, California that’s a Blue Zone. It’s the Seventh Day Adventists. You see that … There’s certainly like when Mark Hyman did the Saddleback Church where everyone got healthy. It was based in a church. What role did you see that faith played in the structuring of the community and the ability of the community to interact and support each other?
Dr. M. Chandan: You highlight some fantastic examples. I think faith communities are very special in many ways. I think also however some of the special aspects, some of the benefits you get from a faith community, some of them you can get from a non-faith community, from any other community, from a diabetes patient group, support group or from a weight management group or from so many other different things. But I think the key aspect of it is … it comes down to trust, compassion and probably truthfulness as well. I think for us here in Birmingham the faith community that we’re working with puts compassion at the very core of what they do and selflessness at the core of what they do. I think these are very broad human concepts that everyone can bind to. Everyone feels that compassion and truthfulness is the right thing to do. So when we have an organization that’s built on that as its core principle that’s running through, flowing through everything that it does that’s something easy to get behind.
The other benefit of faith communities is that also they’re very well established. I think that’s something that for healthcare can actually be used to their advantage.
James Maskell: Yeah. Totally. I really see it as a big opportunity. Just to take it a bit further, I mean ultimately what we’re interested in here with the announcement of our health collective and co-operative is to incentivize groups to be able to take care of their own health. If a group of people could reduce their appointments with their doctor by 20% and could reduce their pharma spend by 10% and the benefits of that could accrue to the people who actually do it directly, that for me is a model that has the potential to be super transformative. Because now … In the NHS I can see where there’s a little bit of that. I’d love to save the government a little bit of money but there’s also a lot of people that hate parts of the government. There’s also whatever. I’m just going to… But in America it’s definitely people have been separated and therefore it’s sort of the best way to take advantage of your health plan is to use it the most. Ultimately, we need to realign those incentives.
Although we are building now the first health co-operative my vision is really that eventually we would have smaller subsets of that co-operative for a church group or for a city or for other groups that decided they want to set different rules for their group. By having the community be smaller they’re actually able to take advantage better of the effort that they put in towards doing it. Because ultimately in the days gone by, it wasn’t a nutrition professional who was counseling someone else on how to eat healthy. It was grandma, for free. I think a lot of the things … We’ve over professionalized everything where it’s like, “Oh, do you need a grief counselor? Or do you need someone just to talk to?” I think that by taking this back into the community there’s an opportunity for us to really reduce medicine. Because what is medicine really? It’s just a bunch of resources being used to keep the community healthy. If the community can step in to facilitate some of that we don’t need as much medicine as we think we do.
Dr. M. Chandan: James, I’m completely inspired by everything you’re saying. There’s a couple of things I’d just like to really draw out. Really the first thing that I think is so powerful in what you’re saying is that actually medicine in many ways is an artificial thing. Actually you can even take this deeper. I mean what does it mean to even save a life? Yeah. What does that even mean? At the end of the day, none of us are going to live forever. We’re all going to go and something’s going to get us. People don’t die of old age. People die of something. Yeah?
So our aim therefore is not to save people from disease completely but it’s our aim perhaps to keep people well while they’re free from disease and then when they do have some disease we’ve got to … that’s when medicine steps in. We’ve got to give people treatments or programs or the tools and the knowledge and the motivation to actually tackle that disease, that illness and stay well through that process. Then when it comes to the end then that’s the end. We are there then to support people through that process too. It’s a cradle to grave thing. Actually you’ve hit the nail on the head there. That actually medicine is perhaps an artificial process but actually if we give that power back to the community from where it came then some great things can happen. So I really like what you said there James.
James Maskell: Well Doc, I really appreciate you being on here. You’re in a group of a like-minded community right now in the Evolution of Medicine podcast. Many doctors have come to the conclusion and many other people have come to the conclusion of exactly what we’ve been speaking about today which is community is a stronger force for creating health and medicine. That it needs to be honest. I really appreciate you stepping forward to harness it, keeping track of the data. Is there any way that our community can help and support you going forward? Because I know it’s not absolutely clear where your research will take itself and where it will go from here inside the NHS.
Dr. M. Chandan: I mean, I don’t know what the future holds at the moment. Yeah. But certainly for me focusing on the root cause of problems, focusing on lifestyle factors, broader factors rather than being so quick to prescribe a treatment is going to be the way forward in my routine practice. I mean I genuinely … I wish you guys all the best in America. I really hope this goes fantastically well for you. Who knows? In the future maybe our paths are going to cross at some point. Who knows?
James Maskell: Absolutely. Well look, I appreciate you coming on to share. For anyone who’s listening to this we are in the middle of our pre-sale for the health co-operative. We are looking to realign incentives and create in America an alternative to health insurance that aligns people to support each other and to support each other in ways that reduce healthcare costs. The kind of results you see here today, weight loss, reduction in use of services, reduction in use of pharma spend. These are typical as a result of community engagement and community interaction. So we want to try and find ways to incentivize people to participate in this way, in a peer to peer transaction role, in a community focused role. It’s supporting other people who are facing the same things as they’ve previously faced.
So it’s been an honor to have you here on the podcast. Keep up the good work and we’ll keep up to date with the project. In the meantime, I’m your host James Maskell. I’ve been here with Mohan-Pal Singh Chandan. He’s a doctor in the NHS doing his part to showcase the power of community in medicine. Thanks so much for listening and we’ll see you next time.
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