Better co-ordination needed to manage chronic diseases

Jun 7 2004

A working party report released today calls for the co-ordinated management of chronic disease across primary and secondary care in the UK. 'Clinicians, services and commissioning in chronic disease management in the NHS', jointly produced by the Royal College of Physicians, the Royal College of General Practitioners and the NHS Alliance, makes recommendations on joint working; clinical leadership and governance; and service redesign.

The challenge of managing chronic disease is reflected in a joint statement of the three organisations which prefaces the report:
“As the population ages the future of health care lies in the management of long-term conditions.  This can best be achieved with new models of service provision, championed by clinicians, in partnership with patients.  The joint re-engagement of both primary and secondary care clinicians in the commissioning process is fundamental to making progress.  This report addresses these issues”

Chronic diseases such as asthma, arthritis, COPD, diabetes, dementia and heart failure place a huge burden on the NHS.  Patients with chronic conditions are more likely to see their GP, to be admitted as an in-patient, and to use more in-patient days in hospital than patients without such conditions. Older people are particularly likely to suffer from chronic conditions, often more than one condition, making care solutions complex and adding to the suffering of the individual.

Patients themselves are central to the management of chronic conditions, and the growth of expert patient programmes and self-management tools have supported patients in making choices about treatment and management of their condition.  There are already many innovative and creative chronic disease management programmes in the NHS, some of which are included in the paper as examples of good practice. 

The key to success is the joint development of local solutions to meet local need.  The report suggests that consideration should be given to joint clinical directorates that span primary and secondary care to improve understanding and facilitate the development of infrastructure and clinical governance arrangements.  The authors have also drawn out the factors that need to exist to make chronic disease management programmes a success:

· Clinicians leading change - redesigning care pathways and new ways of providing care.  Their first-hand experiences of coping with out-dated and ineffective systems are instrumental in finding ways to overcome these difficulties
· Clinicians and managers need to work together to identify bottlenecks in clinical and administrative pathways, supporting care packages and other modernisation techniques
· Trust and good working relationships must be built between participants in healthcare provision – between purchasers and providers; consultants and GPs; managers and clinicians; clinicians and other members of the healthcare team
· Teamwork is essential and professional barriers must be eradicated
· We need to know more about how to manage patients who have more than one chronic condition, as treatments for one condition can affect the others
· Patients need to become managers of their own conditions, with the support of expert patient programmes and self-management tools; and services should be provided locally where possible
· Patient information needs to be shared in order to plan services effectively
· Resources are essential – financial, people and time – to develop new and effective models of care – if they are not provided quickly enthusiasm for projects can be lost

The introduction and application of chronic disease management programmes presents an ideal opportunity to bring together healthcare practitioners and managers in primary and secondary care.  For the full set of recommendations please click on the link below.

Professor Carol Black, President of the Royal College of Physicians, said:
“As we live longer the amount of chronic disease in society will almost certainly increase.  Such a challenge requires all members of healthcare teams to work together to make their own particular contributions at the right time and in the right place.  In the patients’ best interests the locus of care will sometimes be in the hospital setting and sometimes in the community.  What we professionals should strive to provide is appropriate unity of care.”

Health Minister Mr John Hutton welcomed the report:

"Tackling chronic disease is a key priority for the NHS. As more and more over-65 year olds develop these diseases, pressure on NHS services will inevitably grow. A key to tackling this is using primary care services in more innovative ways to ensure these older people manage their conditions better and avoid a trip to hospital.

"This report is a welcome contribution to this process. It promotes much closer working between primary and secondary care clinicians and between all health care professionals caring for those with chronic conditions.  This paper may challenge some traditional assumptions - that would be a good thing. We should not shy away from radical change where that is necessary. Above all we owe it to patients who are living with chronic conditions to achieve the best possible outcomes of care."

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