With evidence mounting that chronic illness represents the principal burden on health and social care services, effective management of long-term conditions is a priority. Helen Howson and colleagues explain

With evidence mounting that chronic illness represents the principal burden on health and social care services, effective management of long-term conditions is a priority. Helen Howson and colleagues explain

The World Health Organisation report Preventing Chronic Diseases: a vital investment demonstrated that chronic conditions represent the major burden of disease in both developed and developing countries.

In Wales, chronic conditions are placing growing demands on health and social care services. The Welsh Assembly government recognises that effective management of these conditions is an essential element in improving people's lives and making services more sustainable. This means real change across primary, secondary and social care.

Two pieces of research are helping guide planning and policy. Setting out what is known about the epidemiology of chronic conditions in Wales and in other countries respectively, the reports have informed the future direction of chronic condition services in Wales.

The result is a new approach which draws together all the elements into an integrated plan. The approach is explained in Designed to Improve Health and the Management of Chronic Conditions in Wales: an integrated model and framework for action, published in March this year.

This document sets out a strategic framework and argues for a proactive, planned and managed approach to chronic conditions. Services will work on an integrated basis, cutting through traditional boundaries and ensuring a common focus across all the key players.

It recognises the need to prevent or delay the onset of chronic conditions, stressing the important role local people and patients can and must play in this, as well as what they can do through self-care and self-management to remain independent.

Foundations for change

The Welsh approach creates the context for completely rethinking how services are provided. It would enhance the alignment between planning, commissioning and service delivery and local needs. It brings the latest thinking on the expert patient, care pathways and commissioning models into a single structured and systematic improvement model, which will mean the end of fragmented services.

The model and framework identify eight foundations for change where improvement is vital to achieving this. These are: information and communication; independence and self-care; primary care; prevention and health promotion; service development and innovation; pharmacy; care pathways; and professional development and training.

These threads are being brought together into an implementation plan that will identify the detailed actions needed to create the new services.

Clinical leadership is crucial and a great deal of effort has been put into involving those who will spearhead implementation at the planning phase. Other change models such as communities of interest are already in place to help build and maintain momentum. Implementation is supported by the National Leadership and Innovation Agency for Healthcare (see 'Take me to your leader', below).

A monitoring and evaluation framework is being developed by Swansea University to track changes and ensure that new energy is injected where necessary. This will serve to assess progress, flag lessons and build a database of evidence-based practice along the way.

The challenge

Shifting the focus from acute care to services closer to local communities and ensuring that the right service is in the right place at the right time is the core challenge. Government, the NHS, partner organisations and communities must address it squarely to make full and effective use of resources and create better, more sustainable services and support for those in need.

In addressing this challenge, NLIAH, the Welsh Assembly government and the Welsh Local Government Association are drawing on international experience to develop new approaches to service provision. Denmark and Sweden are two of the countries that have been studied, their experience underlining the importance of bringing about closer integration of primary, secondary and social care.

The learning gained from Denmark and Sweden is being applied in three local projects involving NHS trusts, local health boards and local authorities. These will serve as demonstration projects to show what can be achieved when different agencies work together to improve care for people with chronic conditions.

Take me to your leader

The National Leadership and Innovation Agency for Healthcare (NLIAH) is a national, strategic resource for NHS Wales. It was set up in 2005 to support NHS trusts and local health boards to deliver the ambitious agenda set out in Designed for Life: creating world-class health and social care for Wales in the 21st century.

NLIAH provides expert support across the functions of leadership, service improvement, workforce development, partnership working and governance, all of which have put a strategic focus on supporting the Wales-wide chronic conditions management (CCM) agenda.

The leadership directorate majors on the Care to Lead brand, with a focus on identifying and nurturing talent through leadership development programmes linked to a succession-planning framework. Participants on all programmes identify a work-based project, a real-time local CCM issue focused on service improvement and better patient experience.

The service improvement directorate provides support to help NHS Wales organisations improve CCM. The 2005-06 modernisation assessment process demonstrated that NHS Wales needed to improve most in the area of CCM. As a consequence, improvements in CCM feature prominently in the Design 4 Improvement plans produced by each health community in response to the process.

NLIAH's integrated care pathways programme involves agreement at health community level of three high-level pathways for people with chronic conditions. The service improvement team provides all-Wales support on design and implementation of the pathways, with access to a further NLIAH programme - Skills 4 Change - when training needs are identified.

NLIAH's workforce development unit focuses on the workforce implications of the CCM agenda, assessing the workforce planning, recruitment and continuing professional development aspects of new and enhanced roles. The unit ensures that the need for a flexible and sustainable workforce to deliver the CCM agenda in Wales is reflected in the commissioning of undergraduate and postgraduate education and training of nursing and allied health professionals and the training of healthcare support workers.

Helen Howson is senior health strategy adviser in the Welsh Assembly, Jan Williams is chief executive of NLIAH, and Chris Ham is professor of health policy and management at Birmingham University.