The content on this page has been co-designed and developed by NHS England’s Clinical leaders and local commissioners, who are members of the Quality Working Group and tasked with leading the development of the Quality agenda for the NHS Commissioning Assembly.
15.4 million people in England (over a quarter of the population) have a long term condition, and an increasing number of these have multiple conditions (the number with three or more is expected to increase from 1.9 million in 2008 to 2.9 million in 2018). People with long term conditions use a significant proportion of health care services (50% of all GP appointments and 70% of days spent in hospital beds), and their care absorbs 70% of hospital and primary care budgets in England.
The NHS should be supporting people to be as independent and healthy as possible if they live with a long-term condition such as heart disease, asthma or depression, preventing complications and the need to go into hospital. If they do need to be treated in hospital, the NHS should work with social care and other services to ensure that people are supported to leave hospital and recover in the community.
Areas of Action
We have identified a set of key areas for action. These are actions which will need to be taken forward in partnership between NHS England, Clinical Commissioning Groups across the whole commissioning system, and other partners such as Local Government.
- Helping patients take charge of their care
- Enabling good primary care
- Ensuring continuity of care
- Ensuring a parity of esteem for mental health
- House of Care – a strategic framework for integrated care for people with long term conditions
- Reducing avoidable emergency admissions improves the quality of life for people with long term and acute conditions and their families, as well as reducing pressures upon the resources of local hospitals. The importance of reducing emergency admissions is recognised by the inclusion of an indicator measuring this patient outcome in the quality premium, the better care fund and it is one the of outcome measures against which CCGs are required to set ambitions. The resources below are aimed at helping CCGs reduce avoidable emergency admissions.
- Reducing emergency admissions
- Reducing emergency admissions – section 2 national trends
- Reducing emergency admissions – technical annex
Local case studies
Please click on the links below to access examples of good practice that area teams and local CCGs have supplied. Note: we will be continually updating and building this list of case studies with examples of good practice supplied by local CCGs
- Walsall: Dementia diagnosis
- Nottingham West: Carer support
- Nottingham West: Integrated Pathways
- Stoke-on-Trent: Telehealth
- Stoke-on-Trent: Improving access to phychological therapies
- Erewash: Reducing unwanted variation to deliver efficiencies in PC
- Nottingham North & East: Putting good health into practice
- Nottingham North & East: Improving care for older people
- Basildon & Brentwood: Care for Home Patients
- Thurrock: Rapid Response Assessment Service
- Enfield: Improving care for residents
- London: Specialised Commissioning
- Dudley: The Dudley Dementia Pathway & Gateway Service
- Ipswich & East Suffolk: Integrated Wellbeing Approach
- Ipswich & East Suffolk: Medicines Management
- Ipswich & East Suffolk: Advance Care planning for end of life
- Ipswich & East Suffolk: Osteoarthritis hip pathway
- Birmingham South & Central: Primary Care Qipp Scheme
- South Worcestershire: Improving End of Life & Palliative care
- Coventry: PMC’s
- Coventry: Telehealth
- Coventry & Rugby: NHS CRCCG Clinical Engagement in Commissioning
- Hertfordshire: Involving Patients & Public
- NHS England: Improving Equity of Access to Specialised Communication Aids
Key resources to support local plans
- Children and young peoples diabetes transition specification – This diabetes transition service specification document sets out a best practice model and considerations to be made by commissioners in stipulating and providing services for young people with diabetes through transition and as young adults.
- NHS Outcomes Framework and CCG outcomes indicators
- NHS Indicator portal – access CCG outcome indicators data here, for each domain
- CCG outcomes tool and explorer – The CCG outcomes tool allows users to view maps, charts and tables of individual outcome indicators across CCGs, and to view a spine chart of all the outcomes for one or more CCGs. The CCG outcomes explorer allows the user to explore the relationships between two outcomes or between demographic information and outcome
- The Future of Health Conference on Long Term Conditions – Co-designing the future along with the experts – the people who live with a long term condition.
- Martin McShane’s presentation – Enhancing the quality of life for people with long term conditions
- Commitment to Carers – how NHS England plans to give carers the recognition and support they need to provide invaluable care for loved ones.
People with long term conditions and their carers could be better equipped to manage their own condition(s). Improving people’s health literacy – helping them to understand how they can help treat and manage their condition(s) – along with truly involving them in planning their own care helps improve the outcomes of treatment, prevents deterioration or complications (including admissions to hospital), and makes people feel more in control of their lives. General practice has a vital role in supporting people to take control of their own care. This means ensuring people know where they can access support, having plans in place should complications occur (e.g. asthma attacks) and for foreseeable events (e.g. deterioration in people with dementia); equipping people with personal health budgets where appropriate; and ensuring people have regular appointments with professionals at times that suit them, at intervals when they are most needed (e.g.to interpret test results or handover between services).
Primary care (general practice in particular) is the cornerstone of health support for people with long terms conditions. Not only in terms of its role in supporting people to manage their conditions, through personalised care planning, but also earlier diagnosis of long term conditions and the potential for complication or deterioration; identifying health needs of their community (‘risk stratification’); and ensuring that there are services in place to manage those needs (the commissioning role); acting as a ‘medical home’ for people, developing a care plan and giving them a named contact to support them and co-ordinate their care; and ensuring they are referred to specialist care when needed.
Coordinating the provision of health and social care services to best help people meet their unique health goals offers higher quality care to people and can be more cost effective. This can be driven both by the increased sharing of information and care records between organisations, planning care jointly between health and care services, and the individual, so that it meets their needs. This is particularly true at points of transition between services, such as when children transfer to adults services.
People with long term conditions require ongoing emotional, psychological and practical support. We know there is significant potential for involvement by a diverse range of third sector organisations (voluntary and not-for-profit organisations), who provide services such as befriending programmes, expert patient programmes and self- and peer- support groups. More coordinated support for patients is needed at the end of life in particular. Two thirds of people would like to die at home, but in practice only one third of people actually do so. Care planning for end of life situations should not be limited to those with terminal cancer, but be extended to all those with long term conditions from which they will foreseeably die.
High quality care for all means that we must close the health gap between people with mental health problems and the population as a whole. Addressing mental health and psychological needs will improve the quality of life for the individual, and may also reduce the impact and costs related to ‘physical’ long term conditions, e.g. from chest pain, chronic obstructive pulmonary disease and diabetes. The cost of managing a patient with diabetes and co-morbid depression is 4.5 times higher than the cost of managing a patient with diabetes alone. People must be assessed and treated holistically for their health problems, rather than providing separate services for physical and mental disorders. Psychological therapies are crucial to this.