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Recent health policy in Scotland emphasises a generic approach to the management of long-term conditions in an effort to improve quality of life and address the sustainability of health services.

As people live longer, an increasing number suffer from long-term conditions. Long-term conditions are ‘conditions of prolonged duration that may affect any aspect of the person’s life. Symptoms may come and go. Usually there is no cure, but there are often things that can be done to maintain an improved quality of life’ (1). The 2001 census indicates that one in five of the Scottish population has a long-term condition, affecting one in three households. Long-term conditions account for a high proportion of NHS time and resources, with an estimated 80% of GP consultations, and 60% of hospital bed days being due to long-term conditions.

Management of Long-Term Conditions

Key to the management of long-term conditions is the ability to identify the people with them and deliver appropriate care. It is estimated that 70-80% of people with long-term conditions are most appropriately managed by supported self care, 15-20% are at higher risk of complications and need shared care, and 3-5% are complex cases often with co-morbidities and need intensive professional care. This intensive care often takes the form of ‘care co-ordination’ or ‘case management’.

Policy in Scotland

Management of long-term conditions features prominently in Delivering for Health (2) and Better Health, Better Care: Action Plan (3) with a renewed emphasis on prevention and ‘anticipatory care’. The Community Health Partnerships’ (CHP) Long-Term Conditions Toolkit (4) highlights chronic obstructive pulmonary disease (COPD) and rheumatoid arthritis as marker long-term conditions. A recent Audit Scotland Report (5), focusing on COPD and epilepsy, confirms the need for action at many levels and Living Well with Long-Term Conditions (6) identifies a range of key areas with an emphasis on supporting self-management for long-term conditions.

Ensuring sustainability of health services

Current health policy clearly recognises the need to improve all aspects of long-term condition management including self-care and self-management, support to carers, disease management and case management. This holistic approach is intended to improve the health and wellbeing of patients. However, the policy is also concerned with increasing the efficiency of health services for people with longterm conditions so as to ensure better planned and co-ordinated care, and reduced need for unscheduled health services.

Of particular concern is the huge demand on secondary care that results from emergency admissions. It has been recognised that many of these are for patients with one or more long-term conditions. In Scotland, emergency admission rates increased in the 1980s and 1990s. In Lothian, this increase slowed compared to the rest of Scotland and levelled off in the mid 1990s. There is however, a suggestion that rates are now on the increase again.

How are we responding to this in Lothian?

Primary Care Modernisation Strategy (PCMS)
NHS Lothian’s Primary Care Modernisation Strategy (7) built upon previous work undertaken by the Demand Management Review to refocus local attention on long-term conditions. The strategy emphasised the role of unpaid carers, psychological therapies, palliative care, and the long-term conditions management programmes set out in the new General Medical Services contract.

As a result of the Primary Care Modernisation Strategy, a Lothian Long-Term Conditions Steering Group has been set up to promote consistent developments, link with patient groups, and ensure consistency with other strategies.

Providing Primary Care Services
Patients with long-term conditions have always received substantial amounts of their care from GPs and other primary care professionals. For some conditions, this management was formalised under the Quality and Outcomes Framework of the new General Medical Services Contract of 2004. Lothian has piloted the use of a QOF data analyser (software) tool that enables practices to examine their own activity relating to long-term condition indicators and to compare their own activity with that of similar practices. The Primary Care Collaborative has been focusing on long-term conditions management, with nine practices developing their care of patients with chronic obstructive pulmonary disease (COPD). Further emphasis on anticipatory care is underway, with Lothian setting up a Scottish Enhanced Service Programme for COPD in 2008.

Local action in Community Health Partnerships
The Community Health Partnerships across Lothian, the Lothian Unscheduled Care Service and the acute services have developed plans that are designed to improve the management of long-term conditions and reduce emergency admissions.

CHP Action Teams have been set up to implement specific developments using the national toolkit as a framework. For example, the Scottish Patients at Risk of Re-admission and Admission (SPARRA) model is being used as a tool to identify a cohort of patients predicted to be at increased risk of emergency admission. Primary care services are using SPARRA data to target and deliver an anticipatory care case management approach to high-risk patients.

Many of the interventions aim to shift the balance of care, so that health services anticipate problems and deal with them in a community setting, rather than admit patients to hospital in a reactive way. Turning systems around, however, is neither quick nor easy. Long-term care has received dedicated funding, with continued funding being dependent on reducing emergency admissions. Box 1 illustrates this in a case study.

How do we know we are making a diference?

The Directorate of Public Health examined the evidence for effectiveness of the interventions planned in 2007. However, because of the lack of evidence, many of the planned interventions are derived from a mixture of available evidence, professional judgement and experience. As a result, they may not have the expected impact and indeed may result in unintended consequences (8). Therefore, it is important that they are evaluated in a rigorous but practical way.

Evaluation will assess the new services particularly how they are distributed between different population groups. Evaluation will also assess the processes of setting up the new services, for example how many patients have received ‘case management’, or attended selfmanagement programmes, or numbers of carers receiving additional support. Evaluation of these interventions must look at outcomes beyond a simple reduction in emergency admissions. Rates of emergency admissions however, do not tell us about the quality of the patients’ experience. They may also be difficult to attribute to a specific new service. Studies have shown that it is not appropriate simply to monitor levels of emergency admissions in the group offered the intervention. Comparison with a control group is necessary to prove that change in admission rate is due to a specific intervention, but this is often difficult to demonstrate.


It is increasingly accepted that in examining emergency admissions it would be more appropriate to focus on emergency admission rates for ambulatory care sensitive conditions – conditions that are accepted as amenable to intervention in primary care.

Taking this approach reduces the chance that the outcome measure is affected by factors other than the quality of primary and community care. For Lothian this means that:

  • Given that the population is ageing, there will be an increase in long-term conditions which will be a major challenge for the health services;
  • As many patients have more than one long-term condition, it will be important that services adopt a holistic approach and treat the patient as a person rather than a patient with a condition;
  • As patients with long-term conditions are responsible for their own health most of the time, it is crucial that they and their carers feel supported to take control;
  • Services for patients with long-term conditions will have to be shifted away from hospitals and be based more in local communities, both to improve quality of life for the patients and carers and to ensure sustainability of the services; and
  • Despite the lack of evidence concerning what services work best, it is essential that we try to find out if what we are doing makes a difference
Box 1: Case study

Rose MacLaughlin is a 76-year-old widow who lives with her daughter. She has several long-term conditions (chronic obstructive pulmonary disease, chronic kidney disease, ischaemic heart disease, diabetes and osteoarthritis). She takes 18 different medicines. She can walk slowly with a walking frame, resting at frequent intervals. Her daughter is her main carer and has reduced her work commitments to care for Rose. A care package is already in place, providing a carer for seven mornings and evenings. Rose is known to the district nursing team, and her GP visits regularly to monitor her condition.

Using the SPARRA model, Rose’s risk of readmission to hospital was estimated to be 51% over the next year. Identified as a person who would benefit from case management, Rose MacLaughlin was visited by the case manager and respiratory nurse specialist from the Western General Hospital, following a pre-assessment meeting with the GP to gather information. At the visit, her situation was reviewed, and an anticipatory care plan was drawn up and shared with nine other healthcare workers, including her daughter, NHS 24, and relevant hospital consultants. The anticipatory care plan resulted in:

  • An oxygen concentrator being supplied;
  • A respite programme being put in place for seven times a year;
  • A sitting service introduced for one afternoon per week;
  • A fire and home safety check; and
  • Improved communication between healthcare workers in primary and secondary care