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Chronic disease means living with a long-term condition

Marilyn Eveleigh
Consultant Editor

The new description for a chronic disease is a long-term condition (LTC), according to Gary Belfield, the Head of Primary Care at the Department of Health. At the NiP Event in London in September, he gave a pertinent insight into the burden LTCs are having and are increasingly likely to have on the NHS.
As we prolong life, the vast majority of the population are inevitably going to have to live with the effects of that natural ageing process. That means having an LTC that requires treatment and care to reduce the deterioration and daily trauma and minimise pain for the patient and their carers. Moreover, every day we see many patients that have more than one LTC. They are generally over 65 years old and tend to be the heaviest users of the health service in terms of medication, consultations and acute admissions.
What are the consequences of this for nurses and the way in which we manage patients in primary care?
The new GMS contract has specifically identified 10 chronic diseases that GP teams can manage in a systematic way - coronary heart disease, stroke, hypertension, asthma, COPD, mental illness, cancer, hypothyroidism, diabetes and epilepsy. Practices can opt to improve patient coverage and care under a quality framework - and increase practice income. It will not be any surprise that many registered patients have more than one of the diseases listed in the contract. And our services to patients need to change accordingly.
Primary care nurses need to remain generalists so that they can manage a whole care package for patients, with the patient as the key element, not the disease. Being multiskilled in chronic disease management enhances the generalist role, and it suits the needs of patients to have a one-stop care programme. Referral to specialists, be they medical or specialist nurses, is still an option for the primary care nurse. Smart teams ensure all annual reviews are in the month of the patient's birthday - a real MOT on all systems at one visit!
Hospital waiting lists are unnecessarily cumbersome when patients may be better suited to a primary care-managed disease programme. In primary care centres or surgery settings, GPs with special interests (GPwSIs), practitioners with special interests or outreach secondary care consultants should review and triage patients for hospital-managed care. Care packages are developed with the emphasis on keeping the patient at home, supported by management plans that are shared by multiprofessional teams.
This model is ideally suited to the skills of supplementary prescribers whereby the patient's care plan is nurse managed and medication altered as necessary. Monitoring patients taking four or more repeat medications is part of the GMS contract and likely to be undertaken by nurses managing chronic diseases.
Watch out for patient empowerment in the shape of self-management plans and efficient referral pathways, supported by the expert patient offering insight and practical options to other patients. I predict that they will become the cornerstone of patient care for those with LTCs.
This edition is dedicated to chronic diseases - those LTCs that will affect almost all of us at some stage in our ageing years. The articles will provide valuable knowledge to support your patient care. In addition, look out for the other NiP events in Birmingham and Manchester and register early - chronic diseases will always be on the programme.