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
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
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
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