In response to an ageing population and the growing demands upon our health service, the management of patients with long-term conditions has been an NHS priority since the 1990s. With the introduction of quality, innovation, productivity and prevention (QIPP), this is now a major work stream for the NHS. The identification and management of those patients within a multi-disciplinary environment, which crosses health and local authority boundaries, is the new challenge. It is widely believed that by improving the quality of care for patients with multiple morbidities (patients with more than one long term conditions) and working collaboratively with the community it is possible to reduce the cost to both health and social care.
The Department of Health (DH) has stated that “there are around 15 million people in England with at least one
long-term condition – a condition that cannot be cured but can be managed through medication and/or therapy.
There is no definitive list of long-term conditions – diabetes, asthma and coronary heart disease can all be included.”1
The World Health Organisation (WHO) defines long-term conditions (also called chronic conditions) as “health problems that require on-going management over a period of years or decades.” The WHO reports focus upon the opportunity for early intervention, proactive action, the use of technology and changing the balance away from hospital to self-care.2
The following list includes areas commonly identified as long term conditions:
‘The LTC QIPP work stream has sought ambitious change in the care model for people with long-term conditions on a large scale, at a time of huge change in the structures and mechanisms of the NHS’.3 QIPP targets are focused upon the reduction of non-elective emergency admissions and the reduction of length of stay (LOS) in secondary care. The reality is that we are all being asked to do more with less, and improving the quality of care of our most resource-intensive patients is perhaps the most obvious place to start. The basic economics of the issue are summed up in the Pareto Principle: that 80% of the resources are consumed by some 20% of the population.
So where do we start with this gargantuan task? The King’s Fund inquiry into the Quality of General Practice suggests that ‘population management’ is key: the activity of proactively identifying individuals who are at risk of deterioration with the intention of then developing interventions to help slow that deterioration and avoid the need for institutional care.4 The inquiry suggests that where interventions are appropriately targeted, there is a high potential for improving patient outcomes. It should be remembered that this cohort of patients can never be cured, but by improving their care and giving them the confidence and skills to effectively self-manage their condition(s), we reduce the burden upon the health and social care systems. The other key to the process is that of collaborative working, combining the resources and data owned by primary, secondary and social care to improve patient outcomes and improve the quality of their care.
In essence, we often see GPs making home visits to patients who have recently received a visit from community nursing staff, and who already have several scheduled social carers attending throughout the day. The same patient then may later make a call to the ambulance service and or the out-of-hours service, only to be admitted into hospital or intermediate care. This sounds a little extreme, but often patients at home or in sheltered accommodation have multiple engagements with a variety of agencies within a very short space of time.
Currently, no one individual within the care chain has the full picture and so there is often no single care/escalation plan to deal with patients’ increased anxiety or deterioration. By identifying these patients and then collectively discussing and agreeing care/escalation plans, it is hoped to have a more holistic and joined-up approach. This is the rationale beyond multi-disciplinary teams working collaboratively, with the patient at the centre of the model.
Identification of these patients can be done using risk stratification tools, or more simply by searching for patients listed in multiple chronic disease registers within the practice clinical database. If these patients are frequently admitted into emergency care, then perhaps their condition or their anxiety is not being properly managed. These are the patients we should target for review within multi-disciplinary forums, as review within the practice setting alone does not always give the full picture. Opening up the discussion across the care community provides greater insight and a joined-up approach for care planning. Care planning is a powerful way of creating an environment which helps clinicians to support self-management by patients of their own long-term conditions.5
In our own locality we have had our first cluster meetings which saw GPs, community matrons, district nurses, social care and community staff actively discussing patients who were known to all. The GPs telephoned into the meeting, at agreed time slots, and discussed previously identified patients around the table. The pilot has been generally well-received; however, a few late innovators wait to see the evidence and data (reduced admissions and improved patient outcomes) which will measure our success. Nobody disagrees with the principle of managing patients with long-term conditions, so the discussion centres upon the optimal method of achieving this.
Identification of patients is not the only challenge to introducing such a system. Primary care is busy enough without taking on what is often perceived as additional work managing patients who are already well known and attend the surgery on a regular basis. However, evidence suggests that such a care model reduces GP visits, reduces admissions, harmonises the approach between primary care and social care and above all, it improves the quality of the patient experience/care. Health economics suggest that there is no ‘do nothing’ option and that we will all face a reduction in resources if we do not tackle our non-elective admissions.
The sharing of information and patient consent are
other hurdles which need to be overcome for an effective system to be implemented. There is little point in having multi-disciplinary meetings if we cannot share the outcomes across primary, secondary and social care, the community, the ambulance and out-of-hours services. All interested parties need to be able to access the latest agreed plan for dealing with a particular patient, and ensure the patient’s individual needs are met. The patient must remain at the heart of the process.
Integrated care models are springing up across the country and have been pioneered in places such as Dagenham. The generic model used by Berkshire East CCGs is shown in Figure 1.
The Kings Fund concluded that the quality and outcomes framework (QOF) had increased the quality of care for patients with long-term conditions, particularly for patients with diabetes, and had provided more focus for other chronic diseases. However, it also concluded that care quality was in places sub-optimal and highly variable. Therefore by identifying patients with long-term conditions and proactively reviewing them within a multi-disciplinary arena, we have a greater opportunity to provide swift and appropriate intervention. The challenge is to set up collaborative working which blurs the boundaries between health and local authorities, allowing us to share data and resources.
If we succeed, we are placing the patient at the centre of a more holistic system which pools and prioritises the resources at our disposal. The time for waiting has already passed.
1. DH Website. Available at: www.dh.gov.uk/health/category/policy-areas/nhs/long-term-conditions
2. Nolte E, McKee M. Caring for People with Chronic Conditions – A Health System Perspective. World Health Organisation; 2008.
3. Sir John Oldham. LTC for QIPP. LTC QIPP Stocktake [undated].
4. Goodwin N, Curry N, Naylor C, Ross S, Duldig W. Managing People with Long Term Conditions. London: The Kings Fund; 2010.
5. Mathers N, Roberts S, Hodkinson I, Karet B. Care Planning Improving the Lives of People with Long Term Conditions. London: RCGP Clinical Innovation and Research Centre; 2011.
Darryl Braham BSc(Hons), PG Dip, MDA is Project Manager at Bracknell & Ascot Clinical Commissioning Group. He spent the last four years working as practice manager in Bracknell for a six-GP surgery.