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This section of the site contains comprehensive information on long term conditions policy. News, events, policy documents, non-clinical guidance, links and other resources can be accessed here. Information on the National Service Framework for Long term (Neurological) conditions is available here.
Over fifteen million people in this country report living with a long term condition. Long-term conditions are those conditions that cannot, at present, be cured, but can be controlled by medication and other therapies. On this page, Dr. David Colin-Thome, National Clinical Director for Primary Care, introduces action to implement the Government's priority to improve care for people with long term conditions by moving away from reactive care based in acute systems, towards a systematic, patient-centred approach.
The latest evidence continues to support the clear messages about long term conditions:
• People with LTCs are the most intensive users of the most expensive services
• Numbers are increasing due to factors such as an ageing population, health inequalities and certain lifestyle choices that people make
• People with long term conditions are not just high users of primary and specific acute services but also social care and community services and urgent and emergency care
• Ill health among the working population places a significant burden on health and social care
• Long term conditions are by far the leading cause of mortality in the world
• There are huge benefits to the population and financial savings if health and social care communities invest in effective LTC management
The Long term (Neurological) Conditions National Service Framework (NSF) was launched in March 2005. The NSF aims to transform the way health and social care services support people to live with long-term neurological conditions. Key themes are independent living, care planned around the needs and choices of the individual, easier, timely access to services and joint working across all agencies and disciplines involved. The principles of the NSF are also relevant to service development for other long term conditions. This NSF is a key tool for delivering the government's strategy to support people with long term conditions outlined in the White Paper Our health, our care, our say and the NHS Improvement Plan: Putting People at the Heart of Public Services. It applies to health and social services working with local agencies involved in supporting people to live independently, such as providers of transport, housing, employment, education, benefits and pensions.
There is much common ground between the Long Term Conditions strategy and the Long term (Neurological) Conditions NSF, for example, around person-centred care planning, information and support, self care and case management. The strategy will be able to use neurological examples and case studies to illustrate how case management and self care can work. In turn it will rely on the NSF and all other NSF teams (eg renal, diabetes) to lead delivery of disease-specific issues under the broader long term conditions work. However, it is important to ensure that NSF for Long term (Neurological) conditions maintains its neurological focus and a discrete identity under this broader umbrella.
The NHS and Social Care Long Term Conditions Model builds on the wealth of local and international experiences and innovations to improve the health and quality of life of those with long term conditions.
Pro-active disease management can make a real difference to patients with a single condition or a range of problems that threaten their health and well-being. Implementation of the National Service Frameworks is already demonstrating that this approach can have a radical impact on outcomes for patients. Extending disease management approaches is essential to sustaining delivery of the PSA target in order to produce better health outcomes, slow disease progression, reduce disability, ensure better management of the sudden deteriorations often associated with long term conditions and result in improved quality of life for patients and reduced need for admission to hospital.
As patients develop multiple long term conditions, their care becomes disproportionately complex and can be difficult for them and the health and social care system to manage. Such patients have an intricate mix of health and social care difficulties. Because of their vulnerability, simple problems can make their condition deteriorate rapidly, putting them at high risk of unplanned hospital admissions or long term institutionalisation. This is often older people, but could also include children and patients with complex neurological conditions or mental health problems.
The NHS cannot do self care to people, but what it can do is create an environment where people feel supported to self care. This can be done through developing organisational structures and networks, appropriate information, interventions and technology, to give people the opportunity to improve their quality of life, and feel that they are still contributing in their community.
Known as community matrons, these experienced, skilled nurses use case management techniques with patients who meet a criteria denoting very high intensity use of health care. With special intensive help, these patients are able to remain at home longer and to have more choice about their health care.
Information on pilot programmes to demonstrate the use of a whole systems approach to deliver to people with long term conditions the community based and personalised care envisaged in the White Paper Our health, our care, our say: a new direction for community services.
Information and links to nationwide events.
Across the country, the Long Term Conditions team have been impressed by many local examples of improved services within Long Term Conditions Care. Some of these examples are established and supported by data and patient feedback, others are under development and could become examples of good practice. As the site develops we will add new examples and case studies.
Long Term Conditions Team, 2N16 Quarry House, Quarry Hill, Leeds, LS2 7UE 0113 25 46027.
This website and its range of networks are intended to connect people and places to ensure that the good things that are happening in the NHS are known by and influence as many people as possible.
Provides self care skills training to people with long-term conditions.
