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Strategy and implications of managing long-term illness

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The UK population is growing steadily year on year. The increase between 1971 and 2004 was five million, bringing the total to 60 million (National Statistics, 2005). Considering the UK’s migration laws are fairly liberal compared with many other countries, this is not a substantial change. What is of major concern is the dramatic change in age composition towards a rapidly ageing population.


VOL: 102, ISSUE: 01, PAGE NO: 19

Monica Fletcher, PGCE, MSc, BSc, RN, RSCN, HV, is chief executive, Education for Health, Warwick

The UK population is growing steadily year on year. The increase between 1971 and 2004 was five million, bringing the total to 60 million (National Statistics, 2005). Considering the UK’s migration laws are fairly liberal compared with many other countries, this is not a substantial change. What is of major concern is the dramatic change in age composition towards a rapidly ageing population.



Population statistics
There are three key factors influencing the trend to an ageing population:



- Advances in medicine mean we are living longer than ever before;



- The large postwar ‘baby boomer’ population is about to reach retirement age;



- Fertility rates are expected to remain below the replacement rate.



Projected trends to 2031 show that the populations of all age groups under 44 years are set to fall, while those aged 60-74 are expected to rise by about 50 per cent and those over 75 years will grow by a massive 70 per cent (Bootle, 2005).



The most significant and alarming statistic is the change in the support ratio - the number of working aged people divided by the number of pensioners - will fall from 3.3 to 2.6 over the same period (Bootle, 2005). This, coupled with the demise of the extended family and an increase in social mobility, should concern everyone involved in the delivery or planning of services for older people and those with long-term medical conditions.



Management of long-term conditions
As we all live longer, inevitably there will be a concomitant growth in the number of people living with chronic illnesses and many people live with more than one chronic condition. Chronic diseases by their nature are incurable, permanent, progressive and need life-long monitoring and treatment from health professionals. The increased prevalence of chronic disease has been described by Ogle et al (2000) as ‘the epidemic of the future’.



The government has become acutely aware of changing demographics and the resultant effect on the NHS. There has been a succession of documents to improve the lives of the 17.5 million people living with a long-term condition. This number will shortly be well over 20 million people, with fewer young people to care for them. A plethora of policies is being introduced to support this change (Box 1, p20).



Sadly, the glamour of emergency care still grabs the public and the political eye. Chronic diseases do not hit the headlines. Most western health systems are based on acute episodic care, set up to treat urgent need and cure people.



The World Health Organization (2002) states that ‘the acute care paradigm is no longer adequate for the changing health problems in today’s world. We can no longer rely on a model based on acute care and patient-initiated consultations to effectively manage chronic diseases’.



Case management
There is much room for improvement in how care is organised for people with chronic illnesses. The NHS strategy has been based on the Kaiser Permanente population-based stratification (pyramid). A disproportionate number of people with chronic diseases occupy emergency hospital beds: five per cent - 250,000 people - account for 42 per cent of total bed usage, this being the tip of the pyramid.



Case management now is seen as the solution, following the Evercare and Unique care pilot schemes in the NHS. The concept of case management, introduced from the US, is based on the premise of seeking out then appropriately managing the high utilisers of the service - in other words, those with complex health needs. The NHS Improvement Plan (DoH, 2004) describes a new clinical nursing role, a community matron to fulfil the role of case manager, and has set a target to employ 3,000 by 2007. Case management is an excellent concept and evidence shows it can be effective in reducing hospital admissions, but it is questionable whether the creation of a role solely for this function is necessarily the best and only way forward.



Implications for practice
The government has inevitably encouraged the development of case management because the public can see a ‘community matron’; they can be counted and held up as a political win, a new resource to solve a problem. There is a question over whether the NHS can afford this role. This is not so much in monetary terms but because community matrons are experienced nurses with a wide range of clinical competencies, so this will inevitably involve taking nursing skills from other NHS services.



We need staff throughout the NHS who can take on the function of case management. It is a system that relies on good teamworking. This function was once fulfilled by the district nurse, GP and social worker working in tandem.



There has been a shift in policy, with more emphasis being placed on the remaining and much larger part of the pyramid and not targeting all the effort at one end. The 95 per cent of patients below the top of the pyramid are equally important and we need to use disease management to stop acceleration up the pyramid. This involves good systematic care, which is frequently provided by suitably trained nurses in primary care.



Disease management now prevails and has been carried out by primary care for many years. There is also recognition of the importance of keeping people healthier for longer, living normal lives with chronic illness and therefore a greater emphasis on self-management.



Primary health care teams have for years been providing a range of disease management services, particularly in areas such as cardiovascular disease, respiratory care and diabetes. Primary care practitioners should be the gurus of chronic disease management. Eighty per cent of GP consultations are for people with a chronic disease or a long-term condition and eight out of ten NHS contacts are in primary care.



Although the government may only have recognised the importance of good chronic disease management relatively recently, it is not new to primary care. Quality can be improved and this is being addressed via changes in the general medical services quality outcomes framework.



The NHS needs to concentrate on improving the skills of and educating nurses and allied health professionals, not rely on new roles. System reform has created new and exciting roles for many existing practitioners such as health care assistants, pharmacists and emergency care practitioners.



Uncertainties regarding the future employment status of nurses within primary care trusts raised by Commissioning a Patient-Led NHS (DoH, 2005) will lead to difficulties with the retention of skilled nurses. It is necessary to look to the positive contribution nurses can and do make and to assure them that there will be a multitude of opportunities to provide excellence in chronic disease management, as the demand is certainly not going to diminish.



- This article has been double-blind peer-reviewed.



For related articles on this subject and links to relevant websites see

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