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Focus on... long-term conditions

In the first of our in-depth ‘Focus on…’ series, doctors describe how they are redesigning care pathways for patients with long-term conditions (LTCs). Below, Dr David Lyon sets the scene for the challenges facing GPs as they manage LTCs

In the first of our in-depth ‘Focus on…' series, doctors describe how they are redesigning care pathways for patients with long-term conditions (LTCs). Below, Dr David Lyon sets the scene for the challenges facing GPs as they manage LTCs

Many practices starting out with practice-based commissioning (PBC) have concentrated on organising themselves into consortia and on redesigning outpatient activity.

However, the most expensive part of the NHS budget is acute admissions, the majority of which relate to a crisis in a well established long-term condition. If PBC consortiums are going to make a difference to the financial bottom line, they are going to have to focus on acute admissions.

The white paper Our Health, Our Care, Our Say describes a future in which every person with a long-term condition, estimated to be between 15 and 25 million of the UK's population of 55 million, are subjected to a personalised care plan, incorporating both health and social care elements.

Delivering on indicators

To cap it all, the quality and outcomes framework (QOF) is changing, increasing the number of disease areas, the complexity of the indicators of care delivery and the robustness of the evidence required to earn the points.

All this may feel like a daunting burden on the shoulders of primary care clinicians, but at least all of these drivers are pushing in the same direction. If long-term conditions are managed better, practices will do well in QOF, there will be fewer crises resulting in acute admissions and the spirit of the white paper will be delivered.

The Pareto Principle applies; 20 per cent of the people need 80 per cent of the care. So, 80 per cent of the time, the personalised care plan will be quite straightforward. Hypertension is the commonest disease within QOF and a care plan could be extremely simple: tablets need to be taken daily, exercise three times weekly, alcohol in moderation, maintain healthy weight, stay off cigarettes, and have blood pressure checks every six months.

In fact, thinking about a care plan will help identify the 20 per cent with greatest need. Primary care clinicians don't often ask about functional ability but it is a key issue. A simple question such as ‘Can you get out of the house without help?' is a good starting point. If someone can't look after themselves and carry out shopping, cooking, cleaning, washing or dressing, their care plan will be more complex, with an emphasis on social and psychological support.

Care co-ordination

Effective care co-ordination will be required for these complex patients to maintain wellbeing, which will mean close working with social services and the voluntary sector. As primary care serves a registered population, it is the ideal setting to identify those most needy and oversee care co-ordination.

Managing long-term conditions better is crucial for the wellbeing of millions of people now – and for most of us in the future. It is also vital for the NHS and the social care system in the UK. Primary care is the essential building block as it is committed over the long term to serving a registered population. It has already proven enormously successful with QOF. The white paper and PBC may seem intimidating, but primary care can deliver. Nobody else is better placed.

Dr David Lyon is a GP at the Castlefields Health Centre in Runcorn, Cheshire. The practice has pioneered a nationally recognised case management approach. Dr Lyon is also clinical lead for long-term conditions at the Improvement.

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