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.
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.
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
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.