Managing long term conditions – here, there and everywhere

2013 diabetes test

The Health Committee is currently examining the management of long term conditions in the NHS and social care system.  The deadline for written submissions to the Committee, of which there will no doubt be many, falls today.  So can we predict what the Committee will focus on in its evidence session and subsequent report on this subject?  Given the broad scope of the inquiry’s remit, this question is not easily answered. 

The background to policy development on managing long term conditions is somewhat complicated.  Until fairly recently, the Department of Health was committed to developing a cross-government long term conditions strategy, which promised to set out a broad vision for improving the quality of life of people with long term conditions.  This initiative, which has since been subsumed by NHS England’s remit, exposed some confusion about where such a strategy should sit and what its objectives should be.  It was clear that this type of strategy could not work in the same way as a condition-specific outcomes strategy, such as those addressing cancer, mental health or cardiovascular disease.  And yet, it was unclear exactly what the strategy could set out to achieve. 

The natural home for such an initiative in the new NHS architecture is, of course, within Dr Martin McShane’s purview as Domain 2 Director.  The Health Committee should therefore look to develop constructive recommendations that Dr McShane can take into account when developing his overarching strategy for addressing Domain 2 of the NHS Outcomes Framework. 

One of the difficulties the Committee is likely to face in drawing up constructive recommendations is the sheer breadth of diseases which make up ‘long term conditions’ – these are defined by the Department of Health as “those conditions that cannot, at present, be cured, but can be controlled by medication and other therapies”.  Examples include asthma, dementia, diabetes, epilepsy, coronary heart disease, and stroke.  Despite being grouped together in this way, long term conditions are extremely diverse and have as many differences as similarities.  Some are preventable, others are not.  Some require extremely specialist interventions to be appropriately managed, while others are better managed through self-care. 

The scale of the task is further emphasised when looking at the numbers involved – over 15 million people in England are living with a long term condition and the management of these conditions accounts for 70% of the total health and social care budget.  Looking at diabetes alone (which the Committee has highlighted as a key focus of its inquiry) shows the enormity of the task at hand – it is predicted that diabetes will cost the NHS more than a sixth of its entire budget by 2035. 

The management of long term conditions should therefore be at the heart of NHS and social care decision-making at every level – this is because the tenets of what makes the management of long term conditions successful are the same tenets that make a good healthcare system.  Dr McShane’s task in developing the Domain 2 strategy will be to show how each of the constituent parts of the new NHS, including patients, will work together to deliver better quality of life for people with long term conditions.  The strategy will need to sit above the disease-specific outcomes strategies and set out the interplay between them, as well as the interplay between the NHS, social care and public health services on which their success relies. 

Measuring the success of the Domain 2 strategy will not be easy.  Neither the Department of Health nor NHS England has yet produced a definitive list of the conditions it considers to be long term.  Without this, it is impossible to count accurately the number of people affected or to assess what the common health issues they face are (or what interventions are required to address them).  The Domain 2 strategy will need to succeed where other attempts at long term conditions strategies have failed.  The answer is not simply to pick up where the Department of Health left off in its attempt to develop a cross-government long term conditions strategy.  There needs to be clear ownership of the Domain 2 strategy to drive it forward and accountability for how its objectives are met.  This will only be possible if a clear baseline is established from which to measure progress. 

The Health Committee’s recommendations will therefore need to resonate with this task.  The Committee’s focus on diabetes is, of course, welcome, but the inquiry will need to go beyond one condition, or group of conditions, to develop meaningful recommendations.  The Committee has highlighted nine issues in which it is particularly interested.  Two of the nine issues really get to the heart of what the Domain 2 strategy should be focusing on: first is the ability of NHS and social care providers to treat multi-morbidities and the patient as a person rather than focusing on individual conditions, and the second is the extent to which patients are being offered personalised services. 

The healthcare community will be paying close attention to what the Committee has to say on these two issues.  As Mike Birtwistle has written on this blog before, there is a need to ensure that the long term conditions agenda does not get squeezed out, as has happened in the past.  But, equally, there is a need for clear thought about what role an overarching Domain 2 strategy can play in the new NHS and what objectives it can realistically deliver.