Long Term Conditions
“When you leave the clinic, you still have a long term condition. When the visiting nurse leaves your home, you still have a long term condition. In the middle of the night, you fight the pain alone. At the weekend, you manage without your home help. Living with a long term condition is a great deal more than medical or professional assistance.” Harry Cayton, Director for Patients and the Public, Department of Health (2005).
South Staffordshire Primary Care Trust (PCT) is determined to provide an excellent and integrated service for the large number of people who suffer from one or more long term condition. But, we are also determined to support as many of you as possible to achieve a healthier lifestyle to reduce the risk of developing many of the preventable chronic illnesses and enabling you to live a long and healthy life.
Why are long term conditions so important?
There are five good reasons why long term conditions are so important to the PCT.
1. Number of people affected
At present around 8% of the population suffers from one or more chronic conditions – this equates to approximately 50,000 people in South Staffordshire, and probably a further 50,000 people who are at risk of developing this type of illness.
The whole country will experience a huge increase in the number of older and elderly people in the next two decades as we see the impact of the ‘baby boomers’. This will particularly apply to South Staffordshire (see chart) and because it is this age group who are most likely to develop long term conditions we can predict a dramatic increase in the number of people who will need support.
2. Impact on quality of life
For some, especially older people and those who have more than one condition discomfort and stress is an everyday reality. Chronic disease by its very nature can last a lifetime. It becomes a part of an individual’s life, affecting the way they suffer with other medical conditions and impacting on their family and friends. People with long term conditions are often less independent and important social networks are difficult to maintain because of poor mobility and there are many people who would like to be able to work but cannot because of chronic illness.
3. Cost of health services
Long term conditions have a significant impact on health services, especially for people who have more than one long term condition. It is estimated that around 80% of consultations at doctors’ surgeries are for those who are suffering from long term conditions and around 60% of the total number of days spent in hospital is estimated to be related to long term conditions.
4. Health inequalities
The prevalence of chronic illness varies across South Staffordshire. Unfortunately if you live in certain areas within South Staffordshire you are more likely to develop a long term condition. Many of these long term conditions can result in premature death and the PCT is determined to help all of us to live a longer and healthier life regardless of where we live. The good news is that …
5. MANY LONG TERM CONDITIONS ARE PREVENTABLE
There is a lot we can do to decrease the risk of developing many of the long term conditions or to improve our health if we already suffer from one or more of the many chronic illnesses (See the section below for more information) and this is one of the main reasons why this is such a high priority for the PCT.
What are long term conditions?
Long term conditions include:
- Diabetes;
- Heart disease;
- Stroke;
- Asthma;
- Chronic obstructive pulmonary disease;
- Hypertension;
- Chronic renal disease;
- Arthritis;
- Chronic neurological conditions;
- Skin conditions;
- Mental health and learning disabilities.
More information about any of these diseases is on the ‘NHS Choices’ website
Who is involved in the care and support of people with long term conditions?
Many different organisations, groups of staff and others are involved at some level in your care if you have one or more long term condition. For most people this will mean looking after yourself and perhaps having the support of a carer or carers. It could also mean receiving support from voluntary agencies and receiving advice on how to manage your condition from an ‘Expert Patient Programme’ which is designed to give you the skills and knowledge to empower you and give you the confidence to be independent and to take control of your life. Depending on which condition you suffer from, you should be on your GP’s records and should be reviewed from time to time to make sure you are happy with the management of your illness and that any medication is still appropriate.
A smaller group of people will have more complex needs which may be multiple conditions and they will have interaction and support from more specialist services using multi-disciplinary teams (E.g. GPs, district nurses, specialist nurses, social care) and will have plans of care which are specific to a particular disease, such as the National Service Framework for Coronary Heart Disease (see links at the bottom of the page).
The third group of people with long term conditions are likely to have very complex needs and may also have had unplanned visits to hospital. They will often be supported and cared for in their own homes by ‘community matrons’ or other nurses who work with them to help to manage their condition and to co-ordinate care between health and social care.
Of course, people don’t fall neatly into one of these three categories as needs vary but whatever your long term condition you should be receiving the right type and level of support to enable you to be as comfortable, independent and as happy as possible.
Avoiding long term conditions
Many long term conditions can be avoided or at the very least delayed. We can all adopt healthier lifestyles to keep ourselves as fit and as well as possible. This is especially important to help us avoid illness, or to lessen the severity of a long term illness if we do already suffer from one of these conditions.
We can reduce risks by:
The role of the PCT
The PCT is concerned with the provision of the best and most appropriate care for people with long term conditions (LTCs), as well as the avoidance of all unnecessary hospital admissions. To maintain the health of those with chronic disease requires a long term commitment from clinicians and many other services. It also requires an understanding of the potential problems, both medical and non-medical, i.e. emotional, social, lifestyle and practical.
A long term condition Service Improvement Group has been established to provide a focus for all discussion and service provision involved with long term conditions, implementing a strategically integrated approach to the agenda. This will ensure that there is equitable provision of services across the whole PCT. By working in close professional partnerships, and across boundaries, we will be able to establish integrated, patient-centred health provision. Every long term condition will have clear and seamless care pathways within the community, with easy access to acute care when absolutely necessary.
National policy, context and targets
The Government is responding to the ‘demographic time bomb’ as well as need for improved services and support for the management people with long term conditions.
Policy and strategy documents:
- Supporting People with Long Term Conditions: An NHS and Social Care Model to support local innovation and integration was published by the Department of Health in January 2005. This document set out a strategy for the management of people with long term conditions. One of the main aspects of the guidance is a requirement for local health communities to identify all patients with long term conditions within their population. To provide the most appropriate treatment for each individual, the patients identified should be according to their needs:
Level 1: Supported self care. This level would apply to 70-80% of the Long Term Condition population and involves helping individuals and their carers to care for their conditions effectively.
Level 2: Disease specific care management. This would apply to people who have a complex single need or multiple conditions.
Level 3: Case management. This level would apply to 3-4% of the long term condition population, and requires the identification of the very high intensity users of unplanned secondary care
- Directives set out in ‘Our Health, Our Care, Our Say’ (published in January, 2006) emphasised the provision of improved care for those with long term needs. It suggests that support should be provided in response to people’s choice and needs and it should be convenient to their homes.
Targets:
National Standards, Local Action: Health and Social Care standards and planning framework 2005/06 - 2007/08 (published in July, 2004) sets out the current national target intended to support people with long term conditions (5). The target is "to improve health outcomes for people with long-term conditions by offering a personalised care plan for vulnerable people most at risk; and to reduce emergency bed days by 5% by 2008 (from the expected 2003/04 baseline), through improved care in primary care and community settings for people with long-term conditions".
Current Public Service Agreement (PSA) targets determine that people with long term conditions should be offered a personalised care plan to improve their health. There is also a target for the PCT to reduce the overall number of days spent in hospital as a result of an emergency admission. These aims are closely linked to one another, and will be achieved by offering integrated care pathways within primary care and community settings.
Further information
National Service Frameworks: 
Information for carers
Expert Patient Programme  (467k)
Do you have a long-term health condition? (110k)
Glossary of health and social care terms
Note : All the documents contained within the site are available for download in PDF format. You can download the Adobe Reader from the Adobe website.
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