People with Long Term Conditions

December 18, 2014

People with Long Term ConditionsThe CQC rate Practices against particular population groups

The CQC now inspects and rates practices against six population groups – older people, long term conditions, mothers babies and children, working age, people living in vulnerable circumstances including people with a learning disability and people experiencing poor mental health, including dementia. This article, the second in a series of six articles, will address the ‘long term conditions’ population group and how we could enhance their quality of life by providing a safe, effective and responsive service.

Use of a Significant Proportion of Healthcare Services

15.4 million people in England (over a quarter of the population) have a long term condition, and an increasing number of these have multiple conditions (the number with three or more is expected to increase from 1.9 million in 2008, to 2.9 million in 2018). People with long term conditions use a significant proportion of health care services (50 per cent of all GP appointments and 70 per cent of days spent in hospital beds), and their care absorbs 70 per cent of hospital and primary care budgets in England.

The NHS aims to support people to be as independent and healthy as possible if they live with a long-term condition such as heart disease, asthma or depression, preventing complications and the need to go into hospital. If they do need to be treated in hospital, the NHS should work with social care and other services to ensure that people are supported to leave hospital and recover in the community.

Key Areas for Action

NHS England has identified a set of key areas for action. These are actions which will need to be taken forward in partnership between NHS England, Clinical Commissioning Groups across the whole commissioning system, and other partners such as Local Government.

  • Helping patients take charge of their care
  • Enabling good primary care
  • Ensuring continuity of care
  • Ensuring a parity of esteem for mental health
  • House of Care
    • A strategic framework for integrated care for people with long term conditions
  • Reducing avoidable emergency admissions
    • This improves the quality of life for people with long term and acute conditions and their families, as well as reducing pressures upon the resources of local hospitals. The importance of reducing emergency admissions is recognised by the inclusion of an indicator measuring this patient outcome in the quality premium, the better care fund and it is one the of outcome measures against which CCGs are required to set ambitions.

Evidence of Meeting Patients Needs

As part of the CQC’s reporting they give feedback after inspections about how the Healthcare provider has met the requirements of the six population groups.

Some examples of outstanding and good reports, taken from recent CQC inspections, include:

  • The practice was knowledgeable about the number and overall health needs of patients with long term conditions using the service. They worked with other health services and agencies to provide appropriate support. Staff were skilled in specialist areas which helped them ensure best practice guidance was always being followed.
  • The practice was rated as outstanding for the care of people with long term conditions. The practice nurses had voluntarily carried out an annual stroke awareness clinic at a local supermarket for the last five years. At the clinic they provided health and blood pressure checks, signposting and identification of any underlying health issues. Any issues were then referred on to the person’s GP regardless of the practice or GP they were registered with. A system had been introduced to maximise checks at a new “first assessment” clinic specifically for people with long term conditions. A recall system had been introduced to identify and combine regular tests which were required by people with long term conditions. A large amount of information was available on the practice website with many links to various supportive organisations. Leaflets were also available at the surgery. The practice worked with Salford Clinical Commissioning Group (CCG) and patients admitted to hospital with COPD and asthma problems were referred directly to the practice nurse, who would pro-actively contact them to discuss the nature of their admission and arrange care to minimise any future recurrence. Patients who were part of the unplanned admission national enhanced service and had care plans in place would be contacted by their doctor following any admission.
  • The practice is rated as good for the population group of patients with long term conditions. When needed, longer appointments and home visits were available. Structured annual reviews were undertaken to check that patient’s health and medication needs were being met. For those patients with the most complex needs relevant health and care professionals worked together to deliver a multidisciplinary package of care.
  • The practice is rated as outstanding for the population group of people with long term conditions. The practice ran a number of clinics for patients with long term conditions. Appointment times varied dependent on the needs of the patient. The practice nurse team led on management of long term conditions including reviews and follow ups. The practice nurses visited patients in nursing homes for their reviews if it was required.
  • The practice worked with community teams to avoid hospital admissions and could access intermediate care services by referral. The practice worked with nursing homes in the vicinity and had a dedicated prescription collection protocol.
  • The practice had completed a number of audits on care delivery and outcomes for patients with long term conditions with an aim to improve services. The community team worked with the practice to meet the needs of patients at home. Community teams and practice staff developed care plans for patients with long term conditions to ensure a holistic service was provided.

Enabling good primary care

Primary care (general practice in particular) is the cornerstone of health support for people with long term conditions. Not only in terms of its role in supporting people to manage their conditions, through personalised care planning, but also earlier diagnosis of long term conditions and the potential for complication or deterioration; identifying health needs of their community (‘risk stratification’); and ensuring that there are services in place to manage those needs (the commissioning role); acting as a ‘medical home’ for people, developing a care plan and giving them a named contact to support them and co-ordinate their care; and ensuring they are referred to specialist care when needed.

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Alison Lowerson

GP Specialist


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