As NHS England publishes three new handbooks to support commissioners and practitioners in planning services for people with long term conditions (LTCs), in order to achieve more effective, personalised care, Dr Martin McShane, NHS England’s Director for Patients with Long Term Conditions, explains why they are a vital new tool: 

In Being Mortal, his latest book, Atul Gawande, who recently gave the Reith lectures, goes downstairs in his hospital and begins exploring the issues that have arisen because of the successes of healthcare and its limitations.

His book might be mistaken for being about end of life care but in reality it is about a good life – all the way to the end. It could be said it is about enhancing the quality of life for people with long term conditions.

The successes of the last decades have meant people living longer and often with conditions that would previously have been fatal. As the cancer charity Macmillan point out, cancer is more commonly becoming a ‘long term condition’. We have learnt a lot about how to manage single conditions such as diabetes, asthma or vascular disease, with success, but we could do better.

Simultaneously, more and more people are developing multiple conditions and our guidelines can impose a serious burden of work.

If we are to tackle the demands that long term conditions create for the health and care system then we are going to have to adapt and evolve our approaches to meet the needs of the future rather than the problems of the past. This is clearly articulated in the Five Year Forward View.

We are going to need to proactively identify people, work with them to create a plan and support professionals to work as a team to deliver the best possible care. The need for more personalised, person centred care which engages with the individual and understand their goals and the support they have from carers and the community they live in is vital, if we are to have a sustainable NHS.

This accords with the views of the people served by the NHS. The Coalition for Collaborative Care has brought together a wide group of people and organisations who want to support the changes needed. As one member of the advisory group said, “It means professionals seeing me as a whole person not simply focusing on a list of conditions to be treated. It means designing my health care and support in partnership with me to help me manage my own health and live the life I want.”

This is a big ask but most professionals want to make that change possible. So, in response to requests from commissioners, we have worked to develop three ‘service components’ or ‘handbooks’ to provide practical support for good long-term condition management. The resources are intended as practical support on how to meet the challenge of providing person-centred care through, arguably, the three most important service components:

• Case finding and risk stratification – how to segment a population and provide person-centred care to those most in need, recognising resource constraints;
• Multi-disciplinary team working – how health and care professionals work together to support people with complex care needs that have been identified  through case finding and risk stratification;
• Personalised care and support planning – enabling commissioners and health care practitioners to deliver personalised care. This handbook has been jointly developed with the Coalition for Collaborative Care

The components complement each other and are all key to successful care planning and integrated working. They have been developed by three task and finish groups drawing together experts with experience in these areas including patients, carers, commissioners and health and care professionals. They can be accessed and downloaded from the NHS England website.

The handbooks may not be as literary as Being Mortal but they could help tackle the issues it highlights.

The handbooks are available on NHS England’s website.