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 pathways.
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:
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
co-operation.
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 home.
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 across.
Abstract
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.
References
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 issues.
Conduct: Jacinta Hofstetter says GSCC has pro-employer bias
GSCC conduct: Tricia Forbes wins Care Standards Tribunal appeal
LGA demand inquiry into credit ratings of Icelandic banks
GSCC case: Jacinta Hofstetter's practice slammed by ex-colleague
Details of government consultations
02 October 2008
Private Member Bills
25 July 2008
Government Legislation
25 July 2008
