Frontline clinicians have to think differently in the face of an ageing population and a rising number of patients with comorbidities. By Martin McShane and Edward W Mitchell

Health systems worldwide face the challenge of people living longer and developing conditions that cannot be cured but for which there are approaches and ever more treatments that can mitigate the consequences and potential complications.

It is estimated that there are 15.4 million people with long term conditions in the UK. More and more people do not have one condition but a collection − often a combination of physical and mental health problems.

‘Continuing to focus on individual conditions rather than individuals leads to fragmented, poorly coordinated care’

By 2018 it is estimated the number of people with three or more multiple conditions will have grown from 1.9 million to 2.9 million. In some cases these conditions are synergistic (such as arterial disease, hypertension and heart failure), but many are non-synergistic (for instance arthritis and hypertension).

Continuing to focus on individual conditions rather than individuals leads to fragmented, poorly coordinated care, which is inefficient, ineffective and delivers poor patient experience.

The impact on longevity and comorbidity is starkly illustrated by the fact that older people now occupy the majority of hospital beds. On average in a hospital with 500 beds, 330 will be occupied by older people, of whom 220 will have a comorbid mental health problem and over 100 will have dementia. We have to think and act differently.

Care built around people

To build on current evidence it is important to recognise that comorbidities present a dilemma for frontline clinicians. Evidence is usually based on research that excludes the elderly and patients with comorbidities.

‘Compared with many health systems, the NHS has the potential to rise to the challenge’

How can we tackle this? We will need to ensure that care is personalised, built around the needs of the individual, and that they are given as much control over their treatment and management as they want and is possible, so they experience person centred, coordinated care (the narrative from National Voices).

To make this a reality, we need continuity of care. This requires three elements:

  1. Informational continuity: a person’s records are available when and where they are needed, across care settings, eg: health and social care.
  2. Management continuity: we need to put in place levers and incentives that promote and support continuity of care.
  3. Relational continuity: that people have a trusted adviser they can turn to for help and advice.

The NHS needs to embrace digital technology in the same way so many other industries have to help us meet the changing nature of healthcare.

Pursuing quality is why the quality framework has been developed and will continue to be developed as we shift towards care built around people rather than process targets.

A solid foundation to build on

Compared with many health systems, the NHS has the potential to rise to the challenge. A recent Commonwealth Fund study reported we have some of the best primary care in the world. That does not mean it is perfect or does not need to change but it provides potential and a foundation for tackling proactive care for people with long term conditions.

The registered list and the continuity of care that general practice can offer makes it easier to implement a “triple therapy” for long term conditions. The triple therapy is:

  1. Population risk stratification;
  2. person-entred care planning; and
  3. multidisciplinary working.

Professionals are accustomed to looking at individual diagnostic results on a regular basis. Risk stratification is a population diagnostic. It raises awareness of the scale and nature of the problems in a GP and clinical commissioning group population. It can help inform the treatment plan, ie: commissioning the right services to meet the needs of the population. It can help inform team working and the importance of participative, truly person centred care planning.

This is why, at the heart of the narrative for domain 2 of the NHS outcomes framework (enhancing the quality of life for people with long term conditions), we have put together the “House of Care”. It is a metaphor to guide thinking about how to support person centred, co ordinated care in a population, and how person centred care planning can be used to support delivery.

Commissioning should be thought of as a quality improvement cycle. Contracting and procurement are a component of the commissioning cycle − an important part but not the only part.

Building blocks

The roof of the “House of Care” contains the pathways, guidance and processes that are also important but must be viewed as a means to an end, not an end in themselves. The pillars, which support the roof, are empowerment of individuals and their carers along with professional collaboration.

The house will not deliver person centred integrated care unless all the architectural elements are in place, and given equal attention. One component alone will not address what is needed for each and every person, no matter what their condition.

‘The uptake of digital health will be driven by the inexorable appetite that people have for minimising the burden of illness on their lives’

By rebuilding the system with the individual at the centre we will move away from our current focus on individual conditions and towards achieving patient goals. That does not mean the processes and evidence we have accumulated should be discarded. We need to keep true to best evidence and treatment; we still need to support people to manage their conditions with the ‘medical musts’.

The “House of Care” is derived from the Year of Care programme, which has transformed care for people with diabetes. However, the house is not condition specific − it is person specific, and the services that support person centred, coordinated care can be tailored to suit the individual.

Digital health

Adoption of digital health tools will increasingly allow those with long term conditions to conduct health transactions remotely and at their convenience (for example, repeat prescriptions, appointment booking, health monitoring and even consultation).

While these services may not be used by every person, the uptake of digital health will be driven by the inexorable appetite that people have for minimising the burden of illness on their day to day lives, while getting the best outcomes as possible. Digital health supports patients, professional collaboration, commissioning and adoption of best practice.

The reforms offer an opportunity to forge communities of care where, building from the registered list, clinical commissioning groups can work with their health and wellbeing boards to align their services with other important sources of support for people with long term conditions, such as social care and housing. They can mobilise the potential of voluntary and charitable groups, as well as commissioning community and mental health services to further support collaborative working. The focus on integrated care will assist with this direction of travel, and there are some striking examples of where this is happening (see box below).

NHS England is committed to supporting this direction of travel and is working to enable the right incentives and tools that will help clinical commissioning groups realise that it is both entirely possible and vital to enhance the quality of life for people with long term conditions.

Case studies on integrated care

  1. The introduction of a single point of access service for rehabilitation and reablement in Greenwich (spanning both health and social care settings), has reduced the numbers of people entering residential care by 35% and saves approximately 60 accident and emergency attendances or hospital admissions a month.
  2. Integration of a memory service into a Gnosall GP surgery (rather than operating as a “standalone” secondary care service) resulted in more comprehensive assessment of the patient, in the context of their community, and tailored support from a practice based dementia adviser. Popular and well received with users, total use of hospital and specialist services was £450,000 less per annum than predicted for this group of patients (principally through avoiding hospital admissions).
  3. Integrated commissioning of acute, primary, community and social care with pooled budgets in Torbay resulted in a significant reduction in acute hospital admissions, length of stay and waiting times for social care. A similar “shared care” model (working between primary, community, secondary and social care) for people with multiple long term conditions at three “chronic care management” demonstrator sites in Wales achieved overall cost reductions of £2.2m from 2007-09.

Dr Martin McShane is director of domain 2 of the NHS outcomes framework at NHS England; Dr Edward W. Mitchell is Faculty of Medical Leadership and Management clinical fellow, the NHS England medical director’s clinical fellowship

NHS England and UCL Partners will be holding a major conference on long term conditions and co-morbidities on 3-4 October 2013 in London. For further details, please see