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Preparation for practice in chronic disease management

Monica Fletcher
MSc BSc(Hons) RGN RSCN HVDip PGCE
Chief Executive
National Respiratory Training Centre
Warwick

Since its inception the NHS has focused more on acute care than on chronic health problems. This focus has also been the drive of the numerous NHS modernisation initiatives, such as:

  • Reducing waiting lists both for outpatient ­appointments and for elective surgery.
  • Improving access to GP surgeries.
  • Reducing the waiting times in accident and ­emergency departments.

However, over the last year there has been a shift in emphasis, and the government is now concentrating more of its efforts into improving the care of the 17 million people living in the UK with a chronic condition. The term chronic disease is being replaced by "long-term conditions" to reflect the change in emphasis from a purely medical approach to a more holistic one that centres on the patient and other aspects of support such as social services.
This change in priority has come about because of the realisation that people with chronic diseases consume a large percentage of our health resources. According to HES data (2000), 50% of bed use is accounted for by 2.7% of medical conditions, many of which are chronic diseases. Around 80% of consultations in primary care involve people with chronic diseases,(1) and 60% of adults report some form of long-term chronic health problem.(2)
The problem is set to worsen, and by 2020 the World Health Organization predicts that chronic diseases will be the leading cause of disability and the most expensive problem for health services worldwide.(3)
Life expectancy is also rising. In the UK, as across the rest of the western world, we have an ageing population.  Scientific advances and improved lifestyles have reduced mortality rates and prolonged lives. There is a concomitant growth in the number of people with chronic disease. It is likely that 75% of people aged over 75 years have a chronic condition.(4)
Ogle et al describe chronic diseases as the epidemic of the future.(5)
Having one chronic condition unfortunately does not protect you from developing another, so the chances of individuals developing more than one chronic condition are continually rising. Cardiorespiratory diseases account for over half of all deaths in the UK, and asthma, heart disease, hypertension and chronic obstructive pulmonary disease (COPD) represent a major burden of ill-health. There are also over 1.3 million people living with diabetes and another million undiagnosed.
Chronic diseases by their nature:

  • Are long-term.
  • Are incurable.
  • Are progressively worsening.
  • Have a major impact on people's quality of life.

It is therefore no surprise that the majority of chronic disease is managed within primary care. The modernisation agency has produced a strategy for the management of chronic long-term conditions (see Figure 1). This subdivides chronic disease management into three levels, which require different interventions:

  • Level three concentrates on case management: dealing with patients with comorbidities and those requiring complex care packages.
  • Level two is about disease/care management: ensuring systematic monitoring and care by ­appropriately prepared practice teams.
  • Level one is support for self-management: ­recognising that most care for long-term conditions is provided by individuals and their arers.

[[NIP22_fig1_41]]

There are significant implications for primary care and its workforce as a result of this change in strategy. Many practices are already beginning to separate chronic care from routine acute care. There are new and evolving roles and responsibilities for nurses, GPs, pharmacists, health educators and lay workers. It is increasingly important for healthcare professionals to be able to understand, treat and manage a number of long-term conditions effectively.
It is evident that primary healthcare professionals (and others such as those working in social services and the ambulance service) will need not only to enhance their clinical skills in a whole range of different chronic diseases, but also to work in a multidisciplinary way - between primary and secondary care and within primary care. New patient-centred consultation skills will also be necessary.
In response to this changing policy agenda and the requirements for the new primary care workforce, the National Respiratory Training Centre in Warwick, Heartsave in Oxford, and Warwick Diabetes Care at Warwick University have been working collaboratively to produce a new diploma in chronic disease management. The three organisations all have impressive track records in running evidence-based, patient-centred training programmes for primary healthcare professionals in the management of their own areas of expertise. However, they felt so much more could be achieved if they worked collaboratively to produce a chronic disease management programme across all their specialties, because in the field many practice nurses are already working across several disease areas.
The team have worked through the Open University to produce two new educational packages: first, a new standalone module for chronic disease management that has been accredited at 30 CATS points at level two; and secondly, a full diploma in higher education in chronic disease management. The programme is designed for all health professionals but will be of particular relevance to nurses working in primary care or managing the primary/secondary care interface.
The chronic disease management programme will develop knowledge and skills, enabling students to set up and run chronic disease management clinics, or to support people with complex needs to limit unplanned hospital admissions; the structure is designed to provide individuals with the opportunity to choose a combination of modules that best suit workplace needs.
The diploma programme is validated by the Open University and carries 120 CATS points at level two. Students are requested to take the chronic disease management module as a compulsory module and then they are able to select from a range of other modules from across the three organisations, such as:

  • Coronary heart disease.
  • Heart failure.
  • Asthma.
  • Chronic obstructive pulmonary disease.
  • Diabetes.
  • Smoking cessation.

References

  1. Morbidity statistics from general ­practice. Fourth National Study 1991-1992. London:?HMSO; 1995.
  2. Office of National Statistics. General household survey (2001-2002). London:?ONS; 2002.
  3. World Health Organization. Reducing risks, promoting healthy life. WHO report. Geneva:?WHO; 2002.
  4. DH. Improving chronic disease management. London: DH; 2004.
  5. Ogle KS, Swanson GM, Woods N, Azzouz F. Cancer and comorbidity: redefining chronic diseases. Cancer 2000;88:653-63.

Resources
National Primary and Care Trust Development Programme
Chronic Disease Compendium
W:www.NatPaCT.nhs.uk
Department of Health
W:www.dh.gov.uk