What did the government promise?
Long-term conditions have only recently become a focus of government concern. They were barely mentioned in the 2000 NHS Plan, which set out its blueprint for wide-ranging health service reforms, and they merited only a brief mention in the Labour party's 2001 manifesto.
By 2000, the Department of Health had issued high-level quality targets – National Service Frameworks – for the treatment of diabetes, coronary heart disease and mental health by primary care trusts, hospitals and GPs. But it took until 2004 for more detailed guidelines about the treatment of people living with long-term conditions to be published.
In the same year, a new long-term conditions target was agreed by the Department of Health and the Treasury, in the form of a Public Service Agreement. This new target specifies that the number of 'emergency bed days' – many of them accounted for by people with long-term conditions – should be reduced by 5 per cent between 2004 and 2008. It also indicates that personal care plans must be offered to all vulnerable, high-risk people living with long-term conditions.
The government's 2004 NHS Improvement Plan acknowledged long-term conditions as a key NHS priority.
How do long-term conditions affect other NHS activities?
Labour's long battle against waiting lists aimed to boost 'production' in hospitals. For example, more staff would do more planned operations, more often.
As the strategy of extra investment and closely monitored targets began to reduce waits for procedures such as hip replacements and cataracts, policy-makers began to take a closer look at increased emergency activity in hospitals.
In fact, just two per cent of patients with long-term conditions account for 30 per cent of emergency hospital admissions, and 10 per cent of in-patients with long-term conditions account for over 50 per cent of hospital bed days. It became clear that high-quality primary and community care could play an important role in reducing both.
Prompted by this evidence, the government began to look for ways of delivering better-targeted health care so that those people affected could remain healthier for longer, have a better quality of life and avoid expensive hospital admissions.
What strategies have been proposed?
Three main strategies have been proposed to improve care for people with long-term conditions.
Case management
Case management - personalised care packages tailored to the complex needs of high risk individuals – will be developed for the three to five per cent of people with multiple, complex conditions who are at greatest risk of hospital admission and require intensive health and social care support.
This approach draws on work in the United States, where private health care providers have pioneered case management in order to keep people with long-term conditions out of hospital and keep costs down. Around £4 million has been invested to pilot Evercare, a US case management model.
An early evaluation of the pilot attributed only a minimal reduction in hospital bed days to the case-management of patients. Despite this, case management is being rolled out nationally. By March 2007, it is envisaged that 3,000 'community matrons' will be acting as case-managers, although recruiting these nurses from an already overstretched workforce may prove problematic.
Challenges ahead include improving information systems sufficiently to be able to identify high-risk patients; developing closer links between hospital specialists and community clinicians; and bridging the gap between health and social care providers.
On balance, even in the absence of hard evidence for the effectiveness of case management, it looks as if the approach may offer the best way forward in managing high-risk patients.
Disease management
Disease management - involving regular monitoring of how well patients are sticking to their treatment, and supporting patients to manage their conditions better themselves - will be developed for the 20 to 25 per cent of people whose health is deteriorating and who may enter the high-risk group.
Under the terms of the new GP contract, doctors' pay depends in part on how well they identify, monitor and treat patients with long-term conditions including diabetes, heart disease and epilepsy. National Service Frameworks also provide guidance, and many innovative services are emerging. A number of independent companies are developing disease management services, including computer-guided telephone consultations with patients. However, once again, the evidence for the cost- effectiveness of disease management remains limited.
Self-management
Self-management - help for people with long-term conditions who are well enough to lead full and active lives to manage their own conditions, with support from health professionals - is the third strategy proposed.
Here too, the new GP contract provides incentives for family doctors regularly to review their patients with long-term conditions. In addition, nationally sponsored patient education is being rolled out through the Government's Expert Patient Programme. Further initiatives include better patient information, and the use of peer support, group education and supportive technologies.
How will other government health policies affect these strategies?
The government's vision seems to be that market forces will play an increasing role in driving change in health services, improving efficiency while maintaining quality, and extending patient choice.
For example, under the new financial accounting system of payment by results currently being implemented, primary care trusts will pay a fixed price for each 'episode of care' provided, directly linking hospitals' income to levels of activity.
Foundation trusts will be given new freedoms to develop additional services and to enter into joint ventures with private providers.
The combined effect of these policies is likely to be greater incentives for hospitals to retain care for people with long-term conditions. Yet current Government strategies for this group, as described above, focus on better 'up-stream' preventative care and a reduction of hospital admissions and bed days.
On the other hand, practice-based commissioning, a new policy initiative to allow GP practices to hold their own commissioning budgets if they choose to do so, may provide a counter-balance.
Under this system, GPs will be able to provide services directly, refer patients with long-term conditions to hospital providers, or choose from a growing array of community-based services now open to private sector providers.
The likely future impacts such policies on the management of people with long-term conditions remain unclear.
Where to next?
The government has successfully increased awareness of the importance of long-term conditions, and their effect on both individuals and the NHS.
But some important challenges remain. On a practical level, one will be to develop the information needed to identify high-risk patients – and skilled staff capable of using it. Another will be building a professional workforce with the skills to help patients manage their own conditions.
On a policy level, there will be a need to manage the potentially contradictory impacts of current policies on the goal of improved community-based care, and, critically, to assess the role of market forces.
While market forces look set to play a key role in areas such as faster delivery of planned surgery, what role might they have in services for people with long-term conditions?
It is hard at this stage to judge. There is some evidence to suggest that what patient groups want most is excellent local services – not greater choice between an array of providers. At the same time, greater choice may play a role in encouraging more innovative services.
