At a strategic level, the last decade has seen the LTC agenda move from a backwater activity into mainstream thinking. Ample evidence has been provided, for example through national service frameworks and NICE guidance, to show that fundamental changes in the way care systems operate are needed to improve quality. More pertinently, the evidence suggests that retaining the status quo is likely to become economically unsustainable unless we can find new ways to manage demand for health care – the majority of which will come from those living with long-term chronic illness.
System redesign is long overdue. Health and social care needs to shift the balance of its business out of institutions into the community and, ultimately, into the home. If we continue with the same business model then we are creating a dangerous mix of higher taxes; reduced entitlements to care; the rationing of treatments; longer waiting lists; and the cutting back on public health initiatives. The financial crisis only adds to the problem of sustainability.
Most changes are brought about through necessity, and there is growing demand to understand what works and what value can be derived from new approaches to care integration in supporting those with LTC needs – for example, enabling people to manage their own care; offering personal health budgets; providing case management to those who need it; and in avoiding unnecessary hospitalisations and nursing home stays.
The coalition government's plans for GP commissioning also suggest a move towards creating a more population-based focus, as GPs would become responsible for the health and welfare of communities in addition to their traditional care of enrolled patients.
However, achieving higher quality care for people with LTCs requires the evolution of multi-specialty, local clinical partnerships, a 'shared care' model of working with other care providers, and more effective and pro-active ways to support patients in the self-management of their conditions. Presently, those working in the system find it difficult to embrace these changes willingly.
Politicians, for example, know that votes lie in protecting the future of a local acute hospital. Arguing that care should be shifted out of hospital, and/or that patients should really take personal responsibility for managing their own care, would be considered 'brave'. Professionals, too, primarily remain focused on traditional ways of working. While there is a momentum to change services for those with diabetes and other specific conditions, there is no professional voice or system leadership to promote the cause of those with long-term conditions – particularly those with multiple care needs. The voice of the public and patients in demanding change too often goes unheard or is undervalued.
We are beyond the tipping point where the LTC agenda can be ignored, but where will the system leadership come from in the New World of the NHS to drive it forward?