Long Term Conditions
The World Health Organisation (WHO) defines long term conditions (also called chronic conditions) as health problems that require
ongoing management over a period of years or decades. This includes a wide range of health conditions including non-communicable
diseases (e.g. cancer and cardiovascular disease), communicable diseases (e.g. HIV/AIDS), certain mental disorders (e.g. schizophrenia,
depression), and ongoing impairments in structure (e.g. blindness, joint disorders). According to the Department of Health, there are
seventeen and a half million people in the country living with a long term condition1.(1)
National Policy Context & Targets
Management of people with long term conditions has recently become a focus of government; several policy documents have been published
which set out current thinking for management of long term conditions. The National Service Framework (NSF) for Long Term Conditions was
published by the Department of Health in March 2005 (2). The NSF particularly focuses on people with
long-term neurological conditions although it is intended that much of the guidance offered can apply to all long-term conditions. The
document set out 11 quality requirements for use in measuring local progress rather than setting national targets and milestones.
In addition to the NSF for Long Term Conditions, a further document, Supporting People with Long Term Conditions: An NHS and Social
Care Model to support local innovation and integration (3), was published by the Department of Health in
January 2005. This document set out a strategy for the management of people with long term conditions. One of the key aspects of the model
is a requirement for local health communities to identify all patients with long term conditions within their area. In order to provide
the most appropriate treatment for each individual, the patients identified should be stratified into one of three levels according to
their needs:
Level 1: Supported self care. This level would apply to 70-80% of the Long Term Condition population and involves
helping individuals and their carers to care for their conditions effectively.
Level 2: Disease specific care management. This would apply to people who have a complex single need or multiple
conditions.
Level 3: Case management. This level would apply to 3-4% of the Long Term Condition population, and requires the
identification of the very high intensity users of unplanned secondary care.
When considering the level of care that a patient requires, the number of times that they are admitted to hospital may be an important
factor.
The Public Health White Paper Choosing Health: Making Health Choices Easier (4) discusses the introduction
of community matrons to work with those with long term conditions, providing personalised care and health advice for those with more complex
problems. It is hoped that this could reduce the need for admission to hospital.
National Standards, Local Action: Health and Social Care standards and planning framework 2005/06 - 2007/08 sets out the current national
target intended to support people with long term conditions (5). The target is "to improve health outcomes
for people with long-term conditions by offering a personalised care plan for vulnerable people most at risk; and to reduce emergency bed
days by 5% by 2008 (from the expected 2003/04 baseline), through improved care in primary care and community settings for people with
long-term conditions".
The target covers all people (including children) with long term conditions, and defines long term conditions as diseases or conditions
which current medical interventions can control but not cure. The most at risk vulnerable people are defined as individuals who have multiple
chronic conditions (on average three) and who make very high use of secondary care. The target guidance states that these people should be
offered a personalised care plan to be implemented through a proactive local care co-ordinator in partnership with the patient him/herself.
The intention is to ensure that proactive and co-ordinated care, as set out in the individual care plans, is delivered in primary and
community settings for these very high intensity users to help maintain their health and avoid unnecessary use of acute inpatient hospital
services.
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