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Meeting the long-term condition challenge

Healthcare possesses a structural deficit that will match and probably exceed the current financial deficit. It is worried about by analysts, think tanks and senior leaders. Yet many GPs, middle managers, and even some foundation trust directors I meet, while recognising the issue, do not always grasp the enormity and imperative of the problem. Here are my tips for how to play your part in restructuring care of long-term conditions in order to meet the huge challenge we are faced by.

1. Understand the scale of the challenge

Today 77% of bed days are due to exacerbations of long-term conditions. Managing people with long-term conditions represents 70% of the total health and care spend in England. Now increase the number of those people by 250%. That is the rise in over-65s that will occur by 2050. If you take just one long-term condition, diabetes, there will be a 188% rise in prevalence. This tsunami of need means if we continue to manage people with long-term conditions as we do now, the NHS is not sustainable. This is not a question of politics, it is a question of mathematics. It is the sentinel issue facing the NHS and will be the determinant of the viability of a clinical commissioning group.

2. Focus on whole-system care – not individual care pathways

By 2013, there will be a 60% increase in the number of existing patients with long-term conditions who will have two or more. These are the patients who are admitted most frequently of all. There is not a health economy in the country that isn't working on management of long-term conditions. The effort and energy however has usually been directed at redesigning disease-specific pathways, often focused on case management as an end point. In doing so, we have unwittingly created a more fragmented system. It brings to mind a MontyPythonesque vision of a line of community matrons outside a single person's house, each dealing with just one of the patient's diseases – and lots of other people calling as well. If you speak to patients this vision is closer to reality than is comfortable. It is sub-optimal care for the patient and palpably inefficient for the NHS. Simply redesigning disease-specific pathways is a redundant strategy for the future and impotent against the challenge ahead. The complacency I meet in too many people about their organisation's current activity on long-term conditions is misplaced. More urgent action is required.

3. Learn from Alaska and the Netherlands

The answers lie within us. We need to look at the places, here and abroad, who do best in managing people with long-term conditions (better outcomes, better patient experience, reduced hospital use), including Alaska and the Netherlands, who are generally regarded in international comparisons as ahead of the game. The best approaches share key elements of their approach, including risk profiling of all patients with long-term conditions, integrated care and systematised, shared decision making.

4. Draw up a risk profile of your population

The best systems involve risk profiling of the population with long-term conditions using validated software that mines primary and secondary care data. Systematic risk profiling identifies not just those at most risk – but those heading that way. From that exercise drops a list of names, call it a virtual ward if you wish, who sit above a certain threshold of risk. Models is use in the UK for predictive risk modelling include the Patients at Risk of Re-admission tool (PARR), Dr Foster High Impact User Management model (HUM), Health Dialog Combined Predictive Model (CPM) and ACG Risk Profiling Tool [1].

5. Nominate a lead healthcare professional for each patient

Integrated neighbourhood care teams involving allied health professionals, community nurses, matrons, social care and GP practices working together have been effective at reshaping care of patients with long-term conditions and preventing unnecessary hospital use. There needs to be a holistic approach to the patient and pathway design using a care team that is multidisciplinary, multi-organisational and acts as one. The team reviews on a weekly basis the list of names from the risk-profiling exercise, and decides upon a single contact person for the patient, whoever is clinically the most appropriate member, who pulls in specialist assistance as and when needed for individual patients. It may be that the contact professional is the nurse with specialist skills in COPD, but he or she will look at all aspects of the patient – not just the one. Thinking down disease-specific pathways is a redundant strategy for the future that is ever increasing multiple conditions.

6. Draw up joint care plans

There needs to significant, systematic effort to create a joint care plan with the patient and actively transfer knowledge about their diseases, to maximise the number who can self manage. Self care already forms a key part of management of patients at level 1 of the conventional car triangle – see diagram. But we need to include some of those patients who would be at level 2 – who are considered at high risk, and would normally be expected to be receiving specialist disease management. The results can be impressive; 20% reduction in unscheduled admissions and length of stay, and a recent Cochrane review showed that empowering people to self-manage their own anti-clotting therapy found a 50% reduction in the number of blood clots and a 36% reduction in deaths.

7. Implement your strategy comprehensively

You need to implement these three elements comprehensively and together. As I go around the country most people are doing something, but usually one part of a PCT will be about self-management, another looking at piloting risk profiling and so on. There is a need to grasp this as a system change; each of the elements alone is insufficient. This is why the very segmented examples of community initiatives in a recent Nuffield Trust report [2] were shown not to work – they were never going to from the outset, it was entirely predictable.

For many commissioning groups putting this sort of system in place will be a step change in current design and mindset. However status quo, or even a moderately redesigned status quo, is not an option. Time is not on our side. This is why the operational phase of the QIPP long-term conditions workstream is co-creating tailored programmes with colleagues in each region of the country to support that step change. We have parts of the jigsaw but we need to bring them together in a determined, comprehensive effort.

Sir John Oldham is a GP and national clinical lead on productivity for the Department of Health