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The challenge of managing long-term conditions
Effective management of long-term conditions (LTCs) is widely recognised to be one of the greatest challenges facing the 21st-century National Health Service in England. Thanks to advances in the care and treatment of many common long-term conditions, a greater proportion of the population is now able to lead a longer and more active life: but this care and treatment consumes a greater proportion of the NHS's finite resources. 70% of total expenditure on health and care in England is associated with the treatment of the 30% of the population with one LTC or more, and the number of people in England with one or more such condition—currently 15 million—is projected to increase to around 18 million by 2025. Care for LTCs presently accounts for 55% of GP appointments, 68% of outpatient and A&E appointments and 77% of inpatient bed days. Cost pressures on the health and care system deriving from management of LTCs and treatment of the increasing prevalence of comorbidities is likely to add £5 billion to the annual costs of the system between 2011 and 2018.
The NHS Call to Action in 2013 demanded improvement in the service provided to support the needs of people with LTCs and to help them manage their own condition. The Health Committee has in the past recognised the structural challenge to the NHS from a lack of integration and coordination of support across the health and care system. In this inquiry we found that in many cases commissioning of services for LTCs remains fragmented and that care centred on the person is remote from the experience of many. The NHS and social care services also face significant financial challenges: demand for services is exceeding the funding available at present, a situation which on present demographic projections is only likely to worsen.
Strategic direction of services for long-term conditions
The Department of Health has committed to improving care for people with LTCs in order to enable them to have an independent and fulfilling life and to receive the support they need to manage their health. An integrated approach to the delivery of health and care services is central to this improvement. We note the commitment of system leaders to ensuring that all localities in England have models for the commissioning and delivery of integrated care and support by mid-2015. In a separate inquiry we will be examining in greater depth the work of the "integration pioneer" sites set up to develop integrated approaches.
The Secretary of State's Mandate to NHS England contains four specific objectives for the management of LTCs, supported by nine progress indicators, though we note that for four of the nine indicators there is as yet little reliable data to measure progress. We call for greater clarity in the setting of baseline indicators and greater transparency and rigour in the measurement of progress against these indicators.
The Department of Health ceased work on developing a cross-Government strategy for LTCs in 2013, following transfer of responsibilities for this work to NHS England. NHS England has not taken forward a national approach to strategic planning for LTCs. It is not clear how effective cross-governmental working is being taken forward in the absence of a national strategy engaging all relevant Government departments. The strategic response from the Government and NHS England to the pressures arising from increased incidence of LTCs is unclear and lacks urgency.
Clinical care for people with long-term conditions
Challenges in defining and recognising LTCs are exacerbated by the increasing number of people who present with more than one LTC, or people with physical health LTCs who subsequently develop mental health conditions. People with such multimorbidities risk experiencing poor coordination of treatments primarily designed to address single conditions. We recommend that NICE take the increasing prevalence of comorbidities into account when developing and revising clinical guidelines for the treatment of LTCs, and take into account the potential risks of polypharmacy—the simultaneous prescription of several medications to treat multiple conditions—to patients with multiple morbidities.
The working definition of LTCs used by the Department of Health no longer captures the complexity inherent in many patients with multiple morbidities, and does not sufficiently emphasise the policy objective of treating the person, rather than the condition, and of treating the person with multiple conditions as a whole. We recommend that the definition be revised to better capture this complexity.
We examined issues arising from the provision of care for people with diabetes, and drew the general conclusion that care pathways needed to be rebalanced to provide greater integration of treatment across all care settings, as well as support for patients to manage their own conditions. The change required can best be delivered through the adoption of individual care planning models centred on the needs of the patient, and we endorse the principles behind the House of Care approach to care planning.
We have identified a systematic and cultural shift towards greater personalisation of health and care services, and greater involvement of service users in constructive discussions about how their LTCs are treated. There is clearly scope to increase the choice patients have over the way their conditions are treated: the challenge for commissioners will be how to evaluate and measure the effectiveness of, for instance, complementary and alternative medicine in cases where a patient feels it is likely to be effective.
Another aspect of personalisation of health and care services for those with LTCs is the greater availability of medical records. While we recognise the considerable benefits in managing LTCs of engaging better-informed "digital patients" with their care, we believe that technological advances to benefit the well-connected patient must not be pursued to the disadvantage of those unable to access digital services.
The substantial structural and cultural changes in clinical care of those with LTCs described in the report will be extremely challenging for health and care services, and will, require medical professionals in all disciplines to adapt their ways of working and develop effective collaborations with those in other disciplines. If more treatment of LTCs is to take place in primary and community care, then the recruitment and workforce planning required must take place as a matter of urgency, in particular to address a work force shortfall in primary care already identified by the Centre for Workforce Intelligence.
Managing the system to deliver better long-term conditions care
The Government is keen to reduce the number of unplanned acute admissions for conditions which could be better treated in primary or community care. We are not convinced that focusing on measures to reduce admissions to the acute sector will effectively address the underlying issues in management of LTCs which seem to drive patients with chronic ambulatory care-sensitive conditions into acute care.
While the prevailing wisdom appears to be that patients with LTCs can be better and more effectively treated in primary and community care, we have not discerned any conclusive evidence that a large-scale shift in services will provide clinical or economic benefits, though a change in service mix may well be beneficial overall in supporting those with LTCs. We recommend the commissioning of long-term studies of the effectiveness and economic benefit from integrated services for the management of LTCs, with regular and rigorous evaluation of outcomes.
We strongly support the development of new payment systems in the NHS, such as the Year of Care tariff, which are based on care planning approaches rather than the funding of individual episodes of care. The integrated care pioneer sites are authorised to experiment with tariff flexibilities, and we recommend that the use of these flexibilities is thoroughly evaluated with a view to developing models of care centred on the needs of the service user. NHS England and Monitor must support parity of esteem between physical and mental health services through the present and reformed tariff system.
What change means for the present structure of services
We were told by the Minister of State at the Department of Health that "significant change" in health and care services for LTCs would be seen across England by 2015, boosted by the introduction of the Better Care Fund and the pooling of a proportion of health and care budgets. It is of course unlikely that the changes in local health systems necessary to support full-scale individual care planning for LTCs will be in place by 2015: the scale and pace of the promised change will only become apparent once clinical commissioning group plans for the shape of local services to 2018/19 are collated and assessed by NHS England.
It is not certain that changes in service design to better support the management of LTCs will be cost-neutral or result in savings in the short term, and it is likely that in the current situation of little or no growth in the overall health budget, the expense of service redesign will have to be met by reductions or efficiencies elsewhere.
Moving care for LTCs to primary and community care and self-management is intended to reduce unplanned admissions to the acute sector. Reducing the activity of acute hospitals on LTCs, and their income from such activity, is bound to have a consequential impact on services. The likely impact of service redesign on the acute sector in particular must be explicitly recognised and openly debated, in order to secure broad public understanding of, and agreement to, proposals for change.
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