NHS system must change to support care planning for long-term conditions
3 Jul 2014 02:18 PM
15 million NHS patients
in England with long-term conditions such as diabetes, arthritis and asthma
account for 70% of the annual expenditure of the NHS in England, the House of
Commons Health Committee says today in a report on a major inquiry into
managing the care of people with long-term
conditions.
The Committee reports that
demographic and cost pressures on the NHS from patients with long-term
conditions is only likely to increase in the coming years, with one projection
estimating that the bill for treatment of long-term conditions will require the
NHS to find £4 billion more each year by 2016. This in a period
when the NHS budget is barely increasing in real terms and when local authority
social care budgets have been cut by £2.6 billion.
Multimorbidities
A long-term condition is defined
as one for which there is no cure but which can be controlled by medication
and/or other treatments and/or therapies. The Committee heard that,
increasingly, patients do not have a single long-term condition but live with
two or more conditions, complicating treatment and adding to its cost. These
multimorbidities, often including physical and mental health conditions, are
not adequately recognised in a system which is overwhelmingly set up to address
single diseases. The Committee recommends that definitions should be reviewed
and approaches changed to emphasise the importance of treating the person, not
the condition.
The Committee has long supported
the integration of the health and social care system, and does so again in this
report. Integration provides the opportunity for better and more effective care
for people with long-term conditions. The Committee finds that greater
integration within the NHS itself is needed to coordinate treatments,
streamline care and ensure that patients with complex requirements are not
passed from pillar to post.
Individual
care
The Committee strongly supports
the development of individual care planning for people with long-term
conditions, based on the principles successfully demonstrated in the NHS House
of Care programme. Care planning approaches will involve GPs, community health
services and specialists sitting down with the patient to draw up a
personalised plan for the care required, which includes the support needed to
help the patient manage his or her own condition. Patients will get a
greater say in their treatment and will be able to discuss what works best for
them.
The challenge of introducing
personalised care planning for 15 million people is substantial. Even now a
shortfall of 17% is projected in the primary care workforce, a situation which
needs addressing urgently to meet the demands that care planning will place on
primary and community care. The Committee notes the scale of the cultural
change required, as professionals across the health and care system develop new
ways of working which put the patient at the centre of care.
Primary and community
care
The Committee looked at the
prevailing view that services to treat long-term conditions should be moved out
of hospitals and into primary and community care, and found that while such
changes might lead to more effective care, the case for economic benefits to
the NHS is not yet proven. In fact to provide effective care for these
conditions, services have to be maintained across all settings, from support in
the home through to acute specialist care, and many conditions will continue to
require specialist services delivered in hospital. The focus on treating fewer
people with long-term conditions in hospital is the wrong one: what the
Government and NHS England should be addressing are the factors which drive
people with long-term conditions into acute hospitals through A&E in the
first place. Cutting acute services for long-term conditions without
ensuring that primary and community care services were geared up to manage the
care of people with long-term conditions would be a recipe for
disaster.
System incentives need a
thorough revision to give proper support for care planning approaches, says the
Committee. Pilot and pioneer projects developing care planning models are
encouraging, but Monitor and NHS England have fallen behind in developing
proper alternatives to the payment by results tariff which is designed for
delivering individual episodes of care, not for managing long-term conditions.
The differential pricing structure adopted for 2014/15 risks disproportionate
cuts in mental health services which call into question the commitment of the
health and care system to establishing parity of esteem between physical and
mental health services.
Collaboration
Effective management of
long-term conditions is not just an issue for the health and care system: it
requires collaboration with other government providers, such as housing and
transport services, to ensure that people with LTCs are properly supported. The
Committee noted that NHS England has moved away from the development of a
national strategy for management of long-term conditions, and calls for clarity
on how cross-government working on LTCs will now be achieved and the strategic
objectives for LTCs which NHS England has now adopted.
The outcome of the present NHS
England planning round will be crucial for the future direction of health and
care services. The Committee calls for open and honest debate about the future
of health services within the available finance.