Key Questions - Long-term Conditions

Heather Sud, RGN, and Jane Gorman, RGN, have a job share as corporate matron, Mayday Healthcare NHS Trust, Croydon, Surrey.

Long-term conditions affect over 15 million people in England and the number is growing. People with long-term conditions have better lives when they are supported to care for their conditions themselves.

What is meant by a 'long-term condition'?

Long-term conditions are those that cannot, at present, be cured but can be controlled by medication and other therapies. They include diabetes, asthma, chronic obstructive pulmonary disease (COPD) and schizophrenia.

How can nurses encourage those with long term conditions to self care?

Self-care is about individuals taking responsibility for their own health and wellbeing, including staying mentally and physically healthy.

Self-care must be led, undertaken and owned by the person themselves and must go beyond clinical care to include an individual's ability to maintain personal interests and social contact. Self care is important as it means:

• People remain in their own home;

• Individuals experience better health;

• Reduction in perceived severity of symptoms, including pain.

According to the National Service Framework for Long-term neurological conditions, self-care can be achieved by:

• Comprehensive assessment and regular client review;

• Access to a range of services including equipment, rehabilitation and accommodation;

• Joint health and social care plans, taking into account housing, transport, benefits and employment;

• Access to the Expert Patient Programme.

What is the Expert Patient Programme?

This is an NHS-based training programme that helps people to build their confidence and motivation and improve quality of life. It takes the form of a six-week course run over consecutive weeks. Participants are taken through structured material covering topics such as:

• Relaxation;

• Diet;

• Exercise;

• Managing pain;

• Communicating with healthcare professionals;

• Fatigue.

Individuals can refer themselves if they wish to undertake the training.

How can community matrons help this group of patients?

When the government drew up plans for improving the delivery of patient care it described a new clinical role for nurses, that is, community matrons. These experienced, skilled nurses work with patients to:

• Avoid hospital admission;

• Give patients control of care and treatment;

• Reduce polypharmacy;

• Improve choice for the patient's family and carers;

• Provide a highly visible professional with clear lines of communication;

• Promote cross boundary contact.

What does it mean to a patient to have a long-term condition?

Nancy Greenwood is a 70-year-old woman, mother, wife and grandmother. Following breast cancer, she underwent sessions of radiotherapy that induced fibrosis of the lungs. This condition worsened each year, resulting in breathlessness at rest 12 years later. Her condition was exacerbated by the onset of rheumatoid arthritis which caused severe joint and muscular pain. and her admissions to the local hospital were <5 within a year. However, chest infections became more prevalent and resulted in chronic anaemia.

Nancy has been in the care of the community matron for six months. Using a stepped approach, her care includes a weekly visit from district nurses to assess mobility, comfort and pain control. The community matron has assessed the effectiveness of non-opiates and facilitated an increase in night-time opiates. This has alowed Nancy to sleep in comfort, in the upright position which she favours for her breathing. She has visited hospital only once within the six-month period for a blood transfusion.