Time for a long-term view

Treatment of long-term conditions has usually taken the form of
treating patients in hospital for short periods of time when the
condition is particularly bad. This results in patients with
long-term conditions (LTCs) taking up a disproportionately high
number of acute beds and hinders an interagency approach.

The needs of the estimated 17.5 million adults in Britain living
with an LTC must be addressed better. Delegates at a meeting of the
Integrated Care Network welcomed the NHS and social care LTC model
outlined in the recent Department of Health strategy.(1)

Delegates were familiar with the “Kaiser Permanente triangle”
model, named after the US medical group, which informs the DoH
strategy. At the base (Level 1) of the triangle, which accounts for
between 70-80 per cent of the LTC population, the emphasis is on
helping individuals and their carers to develop the knowledge,
skills and confidence to care for themselves and their condition.
The “expert patient” is important here, and a strong role for the
voluntary and community sectors is envisaged.

Level 2 involves providing people who have a complex single need
or multiple conditions with specialist services using
multidisciplinary teams and disease-specific protocols and

At the apex of the triangle (Level 3), the case managers have to
identify and manage patients who use a lot of unplanned secondary
care. The innovation here is that the case managers will be
community matrons, 3,000 of whom will be appointed by March 2007.
It is anticipated that matrons will have caseloads of between 50
and 80 patients with the most complex needs, and this will involve
them in more than one general practice. The strategy states that
single largest group of matrons will come from district nurses.

The strategy is clear the model will help ensure effective joint
working between all those involved in delivering care – including
secondary care, ambulance trusts, social care and voluntary and
community organisations – so that patients experience a seamless
journey through the health and social care systems.

Underpinning this will be public service agreement targets for
the NHS and social services that should dovetail neatly. A new
national target for LTCs is to offer a personalised care plan for
vulnerable people most at risk, and reduce emergency bed days by 5
per cent by 2008 through improved care in primary care and
community settings.(2) Linked to this is a public service agreement
target to increase the number of people over 65 supported to live
at home by 1 per cent per year by 2007 and 2008.

With both the NHS and councils expected to take immediate steps
to put the model into action, prospects are good for shared
implementation. But speakers and delegates at the ICN event were
keen to explore some dilemmas.

The first dilemma is how to identify the unplanned hospital
admissions that constitute many of the Level 3 population – the
subject of one of the workshop presentations by Hampshire
Innovation Forum. Identifying which patients to target will require
computer analysis of a lot of data, both of which may not be
currently available.

Many of the unplanned admissions to hospital are from people who
come from isolated and deprived groups that bypass primary care and
are not known to GPs. This means that the acute hospitals have to
be prepared to monitor repeat admissions themselves and ensure the
resulting data is shared with other parties – currently far from a
routine experience.

It should not be assumed that older people are the highest risk
group for LTCs. The workshop on experiences in Dudley reported that
of the 100 people most likely to return to the acute sector on an
emergency basis the biggest single category was chronic alcoholics
with liver problems.

Questions were raised about the proposed community matrons.
Subsequent guidance published by the DoH confirms that the role
will normally be confined to a branch of nursing, and that the
matrons will be located in general practice alongside other
district nurses.(3) Some of those with professional backgrounds in
social work and the allied health professionals queried the
professional restriction imposed by the guidance, and pointed to
the long experience that social workers, in particular, have of
using the case management process.
The danger is that this can detract from the main focus – the
well-being of those suffering from limiting illnesses. Speaking
from the social care perspective, Andrew Cozens, a recent president
of the Association of Directors of Social Services, identified the
following issues:

  • There is no clear incentive to disinvest in the acute sector,
    and insufficient pressure upon the acute sector to co-operate with
    LTC policies.
  • The community matron proposal will not work unless a
    collaborative infrastructure is in place.
  • Primary care trusts are besieged by initiatives and might not
    cope with this new responsibility.
  • Uncertainty over whether councils were willing to let community
    matrons cancel contracts from community providers, and how they
    will cope with the charging element of social care.
  • Uncertainty over the impact of “payments by results” in the
    acute sector, where there is a perverse incentive to retain
    emergency admissions.

Finally, there are concerns about funding and workforce
developments. The LTC policy is predicated upon a shift in
resources from the acute to the non-acute sectors, but this will
not be easily achieved. As Cozens says, PCTs are not strong
commissioning bodies and cannot easily rein in their acute
providers. Indeed, the two parties are in something of a chicken
and egg situation here, for unless emergency admissions are
tackled, payments by results will suck money into acute care, but
it is not easy to address emergency admissions without acute sector

What seems to be needed here is the creation of stronger
incentives to encourage acute providers, especially consultants, to
work with PCTs and social services to reduce admissions. David
Colin-Thome, national clinical director for primary care, told the
conference that the health services’ mouth was “more stuffed with
gold than other areas of the public sector”, and said some PCT cash
should be funding social care.

The DoH has acknowledged that the workforce will need to be
modernised and redesigned to ensure that staff in all three levels
of the Kaiser Permanente triangle have the right skills. Health
visitors and community nurses are an ageing population and
retention is a problem. Allied health professionals are mainly
based in hospitals where it is difficult to use them for
community-based LTC work. And in social care there is a marked lack
of capacity in the home care market that could undermine the
efforts of both health and social care to support more people at

Everyone wants to see an effective LTC policy successfully
implemented, and the DoH strategy is widely acknowledged as an
important shift. What is needed now is an implementation programme
that wins hearts and minds, and that means putting a greater
emphasis upon partnership approaches than has hitherto come


This article reports on a national meeting on long-term
conditions policy held by the Integrated Care Network. It outlines
the new Department of Health policy on long-term conditions and
identifies some of the implementation dilemmas discussed by
speakers and delegates at the event. It suggests that the approach
will stand or fall by the strength of its partnerships.


  1. Department of Health, Supporting People with Long-Term
    Conditions: An NHS and Social Care Model to Support Local
    Innovation and Integration, DoH, 2005
  2. Department of Health, National Standards, Local Action: Health
    and Social Care Standards and Planning Framework 2005-6 – 2007-8,
    DoH, 2004
  3. Department of Health, Supporting People with Long-Term
    Conditions: Liberating the Talents of Nurses who care for People
    with Long-Term Conditions, DoH, 2005

Further Information

Papers and presentations relating to this ICN event are
available on the web site: www.integratedcarenetwork.gov.uk

Contact the Author

E-mail: bob@bobhudsonconsulting.com

Bob Hudson is visiting professor of partnership studies
in the school of applied social sciences at the University of
Durham. He has written and researched on partnership issues for the
past 20 years, and is a specialist adviser to the House of Commons
Education and Skills Committee on partnership and integration


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