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.
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.
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.
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.
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