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Chronic disease: a challenge to the health service

Gary Belfield
Head of Primary Care
Department of Health

In England today, around 17.5 million adults are living with chronic health problems. Of these, as many as 8.8 million live with long-term conditions that severely limit their ability to cope with day-to-day activities.
For some people, especially the elderly and those who suffer from more than one condition, discomfort and stress is an everyday reality. And for the most vulnerable, a lack of coordinated, personalised care can lead to dangerous outcomes and often avoidable emergency admissions.
In just 12 months, one 83-year-old woman in London fell 57 times and came into contact with 14 different professionals before being referred to a case management service. It quickly transpired that simple problems were leading to catastrophic results. A lopsided mattress, for instance, was causing her to roll out of bed and explained why most of her falls happened in her bedroom.
It is important to recognise, however, that health and social care teams across the country are routinely offering quality care to these patients. Examples of local excellence are not hard to find, and frequently nurses, working in new ways, are at the heart of these services.
But now, along with the global health community, the NHS and its partners in social care and the voluntary sector are facing a crucial junction. In England alone:

  • 80% of all GP consultations relate to long-term conditions.
  • 3% of over-65s account for 35% of this group's unplanned admissions.
  • By 2030, the incidence of long-term conditions among the over-65s is set to double.

It's a worrying picture, and one that demands a fundamental shift away from reactive, disjointed care based in acute systems, towards a systematic, patient-centred approach. Care needs to be rooted in primary care settings and underpinned by seamless communication and new partnerships across the whole health and social care spectrum.
So, how can we turn the vision into reality locally? Centrally, the government has taken a strong lead in setting PCTs national targets for improving outcomes for people with long-term conditions. These include:

  • A reduction in emergency bed days of 5% by 2008.
  • The introduction of personalised care plans for those most at risk.
  • A national roll-out of the Expert Patients Programme by 2008.
  • 3,000 community matrons to support people with complex conditions.

The National Service Frameworks, along with the new GMS contract, also place an important emphasis on better chronic disease management in the community. Added to this, the Department of Health is set to publish a new detailed model for managing the care of people with long-term conditions. The model aims to spread the wealth of learning and evidence that is coming out of national and international initiatives, including Evercare - a nurse-led case management approach that has been adapted and piloted by nine PCTs.
At the same time, the long-term conditions model will focus on helping PCTs and practices use the tools they already have to develop a targeted, systematic approach to caring for their chronically ill populations. Among these are disease registers, commissioning flexibilities and a "Quality and Outcomes Framework" anchored in better chronic disease management.
Matching care to need is key. For the majority of people with long-term conditions, significant benefits come from getting better, more integrated support for managing their own symptoms and medication. Initiatives such as the Expert Patients Programme are leading to better health for patients, better medicines compliance, fewer complications and a greater sense of control in coping with day-to-day illness.
There's no single solution to better chronic disease management, but there are some early and vital steps we need to take to identify those most at risk and ensure they don't fall off the radar after each episode of care.
The challenge is to work across boundaries - both cultural and organisational - and develop the integrated, patient-centred services that will transform care for this growing group of people. In all of this, nurses have a leading role to play.