Managing the care of people with long-term conditions - Health Committee Contents

1  Introduction

Our inquiry

1. The Committee set out to examine the way in which the NHS and social care system in England supported people with long-term conditions. In our call for evidence we sought comments on the following issues in particular:

  • The scope for varying the current mix of service responsibilities so that more people are treated outside hospital and the consequences of such service re-design for costs and effectiveness
  • The readiness of local NHS and social care services to treat patients with long-term conditions (including multiple conditions) within the community
  • The practical assistance offered to commissioners to support the design of services which promote community-based care and provide for the integration of health and social care in the management of long-term conditions
  • The ability of NHS and social care providers to treat multi-morbidities and the patient as a person rather than focusing on individual conditions
  • Obesity as a contributory factor to conditions including diabetes, heart failure and coronary heart disease and how it might be addressed
  • Current examples of effective integration of services across health, social care and other services which treat and manage long-term conditions
  • The implications of an ageing population for the prevalence and type of long-term conditions, together with evidence about the extent to which existing services will have the capacity to meet future demand
  • The interaction between mental health conditions and long-term physical health conditions
  • The extent to which patients are being offered personalised services (including evidence of their contribution to better outcomes) 

We address below several of the themes to emerge from the volume of evidence we received in the course of the inquiry.

2. In response to the call for evidence we received almost one hundred written submissions.[2] We took oral evidence from Professor Alan Maynard OBE, Professor of Health Economics, University of York, Dr Karen Lowton, Senior Lecturer in Ageing and Health, King's College London, Dr Sue Roberts CBE, Chair, NHS Year of Care Partnerships, Dr Judith Smith, Head of Policy, Nuffield Trust, Professor Alan Silman, Medical Director and Director of Policy and Health Promotion, Arthritis Research UK, Baroness Young of Old Scone, Chief Executive, Diabetes UK, Dr Peter Aitken, Chair of the Faculty of Liaison Psychiatry, Royal College of Psychiatrists, Don Redding, Director of Policy, National Voices, Liz McAnulty, Trustee, The Patients Association, Dr Peter Fisher, Clinical Director and Director of Research, Royal London Hospital for Integrated Medicine, Professor George Lewith, Professor of Health Research, University of Southampton, Professor Nigel Mathers, Vice Chair of Council, Royal College of General Practitioners, Alastair Buxton, Head of NHS Services, Pharmaceutical Services Negotiating Committee, Emily Holzhausen, Director of Policy and Public Affairs, Carers UK, Victoria Matthews, Assistant Long Term Conditions Adviser, Royal College of Nursing, Dr Martin McShane, Director, Improving the quality of life for people with long term conditions, NHS England and Norman Lamb MP, Minister of State for Care and Support, Department of Health.[3] We are grateful to all those who submitted written evidence and who appeared before us as witnesses.

3. The oral evidence in this inquiry was taken when Rt Hon Stephen Dorrell MP was in the Chair. Mr Dorrell was elected as Chair by the House on 9 July 2010 and resigned as Chair on 4 June 2014. The Committee wishes to place on the record its thanks to Mr Dorrell for his work with the Committee throughout this inquiry.

The challenge for health and care services from long-term conditions

4. The effective management of long-term conditions in the population of England is widely acknowledged to be one of the greatest challenges facing the NHS in the early 21st century. A service which, on current expenditure plans, is unlikely to receive more than the most minimal real-terms increases in its budget until at least 2016 is expected to meet the healthcare needs of a population which is, on average, living longer and requiring greater support. Advances in the care and treatment of many conditions have had the happy effect of ensuring that a greater proportion of the population is able to enjoy a longer and more active life. But such care and treatment require greater expenditure on staff, pharmaceuticals and equipment over a longer period, and consume increasing resources.

5. The Department of Health defines a long-term condition as "a condition that cannot, at present, be cured but is controlled by medication and/or other treatment/therapies".[4] The Department estimated in 2012 that over 15 million of the population of England had been diagnosed with at least one long-term condition.[5] On current trends, that figure was projected to increase by a further 20% to around 18 million by 2025. The proportion of NHS services accounted for by people with long-term conditions is substantial: 55% of GP appointments, 68% of outpatient and A&E appointments and 77% of inpatient bed days. It is estimated that 70% of total expenditure on health and care in England is associated with care for the 30% of the population with long-term conditions.

6. Citing research by The King's Fund, the Department estimates the average cost per year of treatment for a person with a single long-term condition in the health and social care system is £1000. For a person with two long-term conditions the cost is £3000: for those with three the estimated cost is £8000.[6] Without improvement in both the rate of prevention of long-term conditions and the management of those with such conditions, the Department estimates that by 2016 the cost pressures on the NHS will reach an additional £4 billion per annum compared to the baseline of 2010.[7]

7. Further complications come from the increasing prevalence of comorbidities, or concurrent diagnoses of more than one long-term condition. In 2012 the Department projected that the number of those with more than one long-term condition would rise from 1.9 million in 2008 to 2.9 million in 2018, and that the increase in such comorbidities, taken together with the general cost pressures indicated above, would add £5 billion to the annual costs of the health and care system between 2011 and 2018.[8]

8. These basic figures led us to question whether health and care services in England are optimally structured to handle the present number of people in England with long-term conditions in a way which is effective both in providing the best care and treatment possible and ensuring the best use of public money. Nor do they provide any assurance that the system is well-placed to handle future levels of demand.

9. Leaders of the principal organisations in the health and care system have recognised the difficulties posed by trends in the incidence of long-term conditions. In July 2013 the NHS Call to Action noted that expenditure on people with long-term conditions accounted for "a disproportionate amount of NHS resources", and that people living at higher levels of deprivation were more likely to live with a debilitating condition, more likely to live with more than one condition, and likely to do so for more of their lives.[9] The situation required a response from the system:

    The NHS, working with local authorities and the new health and wellbeing boards, needs to be much better at providing a service that appropriately supports these patients' needs and helps them to manage their own conditions. Better management of their own conditions by patients themselves will mean fewer hospital visits and lower costs to the NHS overall, and more community-based care, including care delivered in people's homes.[10]


10. In this report we examine two main and related issues: the principles which should underpin the clinical care of people with long-term conditions, and the way that the health and care system should be managed to support the delivery of such care.

11. The themes which the Committee has covered in its inquiry are in no sense new. They stem from a policy priority which the Committee has consistently championed over the course of this Parliament: that of greater integration across the healthcare system and across health and social care services. In our 2012 report on Social Care, we drew attention to the significant proportion of the population who are now the "typical" users of NHS and social care services: those with long-term and chronic conditions who need coordinated care packages to allow them to lead fulfilling lives.[11] We found that "many older people, and those with disabilities and long-term conditions need to access different health, social care, housing and other services, often simultaneously."[12] We also found that many services which should be joined up for the benefit of the service user instead sat in unconnected silos, kept apart in part by the fragmented nature of commissioning budgets, and we concluded then that there was a link between experiences of fragmented services and the multiplicity of funding streams and commissioners of services. We did not think that the reforms to commissioning structures proposed in the Health and Social Care Bill, now enacted, would simplify the process for commissioning health and care services in this regard.[13] Much of the evidence we received in the course of this inquiry indicated that for service users with long-term conditions commissioning remains fragmented and the delivery of care centred on the person can be frustratingly remote.

12. Our findings in 2012 have since been echoed in the 2013 report of the House of Lords Select Committee on Public Service and Demographic Change:

    We heard that a new model of care is needed, more focused on prevention, early diagnosis, intervention, and managing long-term conditions to prevent degeneration ... A remarkable shift in NHS services will be needed to deliver this new model of care. Older people with long-term conditions want good primary care, community care and social care, joined up around them regardless of clinical categories or structural splits between healthcare on one hand and social care on the other. They want good out-of-hours services, so that their conditions can be managed in their own homes and prevented from deteriorating, and to make it possible to minimise upsetting, disruptive and expensive episodes in hospital. This is not the system we have.[14]

While the Lords report focused on care for the ageing and elderly, in an era of substantial demographic change, the arguments apply to health and care services for all those with long-term conditions who rely on such services to support them in their daily lives.

13. It had been anticipated that a substantial proportion of the necessary change of health and care services described above would have come about during the period of the "Nicholson Challenge", the five-year period during which the NHS has been expected to find up to £20 billion in efficiencies to meet the anticipated cost pressures on the service in an era of flat budgets and rising demand. Having tracked progress against the Nicholson Challenge in our annual reports on public expenditure on health and care services over the course of this Parliament, we have reached the broad conclusion that the scale of change contemplated is unlikely to materialise in the period before May 2015. Since a return to year-on-year increases in real-terms expenditure on the NHS from the public purse appears at present unlikely, and a reduction in the cost pressures seems equally unlikely, it seems to us probable that Nicholson-style restraints will have to continue in some form into the next Parliament and across a future spending round: indeed, NHS England has now indicated that the anticipated funding gap of £20 billion expected by 2015 is likely to widen to £30 billion by 2020/21.[15] The incoming chief executive of NHS England, Simon Stevens, told us that this projection was based on the twin assumptions of flat NHS spending in real terms to 2020/21 and demographic projections of population growth and ageing over the same period: the question he posed to the NHS was "what is it going to take to make significant inroads there?"[16]

14. Social care faces its own funding pressures. In May 2013 the Association of Directors of Adult Social Services (ADASS) estimated that by April 2014 local authority social care budgets would have been reduced by a total of £2.68 billion, or 20%, since the beginning of the present spending round.[17] Budget reductions therefore comprise the greatest present pressure on social care, but demographic pressures are also mounting: ADASS and the Local Government Association told us that, on the basis of their 2013 budget survey, local authority adult social services departments had estimated that demographic pressures would lead to annual increases in demand of about 3%, equivalent to £400 million. This would stretch service delivery, resulting in fewer people receiving services, but at higher cost and intensity.[18]

  1. Challenging decisions on the future shape of health and care services remain to be addressed. It is unlikely that they can be evaded. Our report, therefore, considers the future shape of publicly-funded services for the care of people with long-term conditions in a context of continuing financial challenge for the NHS and for adult social care services.

2   Written evidence received by the Committee is listed on page 85 Back

3   Details of the evidence sessions are given on page 84 Back

4   Department of Health, Long Term Conditions Compendium of Information, 3rd edition, May 2012, p 3. The 2nd edition of the Compendium (2008, p 10) defined long-term conditions as "those conditions that cannot, at present, be cured, but can be controlled by medication and other therapies. The life of a person with a LTC is forever altered - there is no return to 'normal'." Back

5   Ev 74, para 1 Back

6   Ibid., paras 1-2 Back

7   Ev 75, para 4  Back

8   Long Term Conditions Compendium of Information, 3rd edition, p. 6 Back

9   The NHS belongs to the people: a call to action, NHS England, July 2013, p. 8 Back

10   IbidBack

11   Health Committee, Fourteenth Report of Session 2010-12, Social Care, HC (2010-12) 1583, para 5 Back

12   Ibid., para 10 Back

13   Ibid., para 11 Back

14   House of Lords Select Committee on Public Service and Demographic Change, First Report, Session 2012-13, Ready for Ageing?, HL (2012-13) 140, paras 198-199 Back

15   The NHS belongs to the people: a call to action, p. 15 Back

16   Oral evidence taken on 29 April 2014, HC (2013-14) 1219, Q 48 Back

17   "Social care funding bleak; outlook bleaker", press release from the Association of Directors of Adult Social Services, 6 May 2013, available at Back

18   Ev w57 Back

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Prepared 3 July 2014