Over a quarter of the population in England has a long term condition (LTC) and an increasing proportion of people have multiple conditions. The Five Year Forward View (5YFV) notes that ’long term conditions are now a central task of the NHS; caring for these needs requires a partnership with patients over the longer term rather than providing single, unconnected “episodes” of care’.
With £7 of every £10 of health and social care spend targeted towards the 15 million people with LTCs, it is relatively simple to make the case for improved personalised care and support for people with LTCs and their carers. However, it is a much more difficult challenge for commissioners and practitioners to turn this into a reality.
In response to requests from commissioners, we have worked to develop three ‘service components’ or ‘handbooks’ to provide practical support for good long-term conditions management. They draw on the latest research, best practice and case studies to show how this can be done in reality in, arguably, the three most important areas for LTC management. The Executive Summary and Handbooks covering Core Information; Supplementary Information on Practical Delivery and Supplementary Information for Commissioners have been updated and supersede the versions published in January 2015.
- Case finding and risk stratification – identifying cohorts of people with LTCs that are most vulnerable and/or will benefit most from tailored care and support.
- Next Steps for Risk Stratification in the NHS – Recent discussion paper, see Section 3 of the Case finding and risk stratification handbook.
- 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. It includes:
- An executive summary – Updated March 2016
- Core information on personalised care and support planning – Updated March 2016
- Information for commissioners – Updated March 2016
- Practical delivery guidance – Updated March 2016
- Multi-disciplinary team (MDT) working –supporting health and care professionals to work across professional and organisational boundaries.
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. The task groups have been supported by colleagues from the Medical, Nursing, Patient and Information Directorates at NHS England.