Prof.
David Colin-Thomé, OBE
National Primary Care Clinical
Director, Department of Health
To
continually improve the care of patients with long term conditions (LTC) is an
NHS priority. We have National Service Frameworks such as the recently
published framework for chronic kidney disease1 which are
complemented by NICE and provide an evidence based approach to better care. We
have documents such as the Quality and Outcomes Framework of the GP contract
that clinically focuses on Long Term Conditions which features in 80% of all GP
consultations2 and now the added potential of the new pharmacy
contract.
The over
arching NHS and social care model for the management of Long Term conditions
has been produced by the Department of Health in which new categories of
patient need have been devised.
On Level 1
are patients who, with support from their carers, are capable of developing the
skills to monitor and manage their own condition to become empowered, expert
patients.
Patients
who have a complex single need or multiple conditions will be placed on Level
2. They will require responsive, specialist services using disease-specific
protocols and pathways.
The most
vulnerable patients who have highly complex, multiple long-term conditions will
be on Level 3. They will need an intensive case management approach, building
on the single assessment process. It is those patients whom we need to identify
first.2
This
systematic proactive approach to the management of patients with long term
conditions will generally be based in community settings with the potential for
it to be embedded in the general practice.
And if we
are to address health inequalities, what better place to begin as those that
live with social deprivation are more likely to suffer from long term
conditions from an earlier age and more severely.
References
1.
National Service Framework for Chronic Kidney Disease, DoH, 2005.
2.
Supporting People with Long Term Conditions, DoH, 2005.