What is a long-term health condition?
Over a quarter of the population of England (15.4 million people) has at least one Long-Term Condition (LTC), arthritis, asthma, COPD, diabetes, epilepsy, cardiovascular disease (angina, heart failure, hypertension etc) and mental health issues (depression, eating disorders, bi-polar disorder etc).
LTCs are, with their rising prevalence, increasingly important determinants of quality of life and healthcare costs in populations worldwide
These conditions are routinely managed within primary care, but, due to their nature can often go undetected and untreated for many years. This prevents an opportunity for early intervention which could lessen the severity of the illness.
NHS Long-Term Plan
Most recently the NHS Long-Term Plan sets out its ambition to overhaul long-term condition management through increased focus on population health, a reduction in health inequalities, establishment of a digitally enabled primary care system and ultimately an improvement in the management of long-term health conditions.
Proactive Case Management
There is a need to proactively manage patients with LTCs. This is a current issue, particularly due to delays in treatment caused by the COVID pandemic. There is also a need to case find patients who are not aware of an underlying condition and who remain untreated.
Examples of case finding and proactive care tools below
- CDRC Precision digital resources are developed by clinicians in the North East of England, working on existing clinical IT systems (SystmOne and EMIS) and are quality assured by the North of England Care Support Unit (NECS). Dynamic templates help guide and prompt clinical management in line with current best practice. Standardised regional referral information and letters are included, to improve communication, patient care and referral pathways.
You can contact CDRC to access these tools using this link; Resources - Clinical Digital Resource Collaborative (cdrc.nhs.uk)
- UCLP (North West London AHSN) proactive care frameworks provide a platform for optimising clinical care and self-care for people with long term conditions, supporting primary care teams to do things differently and at scale.
Read the descriptions of the support offered for long-term conditions below:
For more information you can visit UCL Partners Proactive Care Frameworks
To access the tools you can visit here
 National Health Service (NHS) England. NHS Outcomes Framework – 5 domains resources. Domain 2: enhancing quality of life for people with long-term conditions. Available from: https://www.england.nhs.uk/resources/resources-for-ccgs/out-frwrk/dom-2/ [last accessed Sep 24, 2015] [Google Scholar]