Long-Term Conditions

Nursing Care and Management

Liz Meerabeau, Kerri Wright

• Publisher: Wiley-Blackwell
• Year: 2011
• ISBN:
  9781444341010
• Edition: 1
• Topic: Medicina
• Subtopic: Enfermería

"This book is a very welcome tool, which will enable health professionals to understand the complexity, challenge and rewards of proactively managing long-term conditions. Putting this knowledge into skilled practice, in partnership with patients, will transform the lives of many individuals and their families, and thus fulfil the fundamental purpose of nursing."
— From the Foreword by Professor Rosemary Cook CBE, Director, the Queen's Nursing Institute and Visiting Professor of Enterprise, University of Northumbria

Long-Term Conditions is a comprehensive, practical guide for nurses and healthcare professionals on the care and management of people with chronic illness. It explores case management, individual care and management, the role of the 'expert patient', quality-of-life issues, counselling skills, self-management, and optimum self-care. Long-Term Conditions discusses the three main long-term conditions currently resulting in most hospital admissions: diabetes, respiratory, and coronary heart disease, with a focus on empowering the patient to self-manage.

Key Features:

• A comprehensive guide to the care and management of long-term conditions
• Focuses on the management of the conditions from the patients' perspective
• Practical and accessible in style

Chapter 1

Long-term conditions in perspective

Liz Meerabeau

School of Health and Social Care, University of Greenwich, Eltham, London, UK

Introduction

All developed countries, whatever their political system and overall approach to health policy, face challenges in meeting the rising costs of health care. This increase in health care costs generally exceeds the rate of economic growth; contributing factors include increasing proportions of older people in the population, the development of expensive medical technologies and drugs, and increasingly well-informed people who demand access to these developments in health care. High Quality Care for All (Department of Health, 2008a), also known as the Darzi Report after the junior health minister who led the NHS Next Stage Review, identifies six challenges common to all advanced health care systems: rising expectations, demand driven by demographics, the continuing development of the ‘information society’, advances in treatments, the changing nature of disease and changing expectations of the health workplace (i.e. staff expect a better work-life balance).

An important element of the changing patterns of disease is the increase in prevalence of long-term conditions (LTCs); LTCs are one of the eight priorities for the NHS. Dowrick et al. (2005) consider that the management of what they term chronic illness is beginning to develop its own identity as an important component of health care, and that despite clinical differences, there are many similarities in the problems people with different LTCs face and the strategies needed in providing care. These include the proactive identification of relevant populations, supporting the relationships between people with LTCs and health and social care, the development of evidence-based guidelines intended to prevent exacerbations, and the promotion of empowerment, for example through self-management.

This chapter discusses changes in the need for health care due to demographic change and persistent inequalities in health, before going on to outline some of the changes both in service delivery generally and in the provision of health care for LTCs more specifically, such as the use of targets by governments, and the growth of patient-focused care. Generally, like the rest of this book, the chapter has an English focus, in which policy initiatives and service developments include user participation (Department of Health, 2003) and National Service Frameworks (NSFs) with specific standards, for example for coronary heart disease (Department of Health, 2000a) and for LTCs (Department of Health, 2005a). Comparisons with the other three UK countries are also made briefly, and the global context is also discussed.

The global challenge: demographic change

Within the overall trend towards older populations, the most rapidly growing segment is that of people over 80: the Organisation for Economic Co-operation and Development (OECD)(1988) estimated that whereas in 1980 the cohort of older people was made up of 34% aged between 65 and 69, 48% between 70 and 79 and 18% 80 or over, by 2050 these percentages would be 26%, 43% and 31%, respectively.

More recently, An Ageing World: 2008 (US Census Bureau, 2009) highlights a huge shift to an older population, with great consequences. In the next 30 years, the number of people over 65 in the world will almost double to 1.3 billion, and in 10 years time, older people will outnumber children for the first time. This will affect family structure, patterns of work and retirement. Europe has 23 of the 25 ‘oldest’ countries in the world (including all of the countries of western Europe, with the exception of Ireland and Denmark). In the United Kingdom, the nineteenth ‘oldest’ country, by 2040 there will be 46 people aged 65 and over for every 100 people of working age (defined as aged 20 to 64); in Germany, the figure will be 58, and in Japan, 68. (This ratio is called the older dependency ratio.) This compares with 16 in South Africa and 23 in India. Japan, Singapore, France, Sweden and Italy all now have life expectancies at birth of more than 80 years. However, although the proportion of older people in the populations of developing countries is much lower, because of the size of these populations, overall most of the increase in the number of older people in the world is actually in these poorer countries. China is one of the fastest ageing countries in the world, since its fertility rate has been below the replacement rate since 1991, due to its long-standing one-child policy. In Japan, 22.5% of the 127 million people are over 65, whereas only 13% are under 15.

It should not be assumed that greater longevity automatically increases the burden of ill health; many people are likely to live relatively healthy lives until their last few years, although it is likely that they will be managing one or more LTCs. The Academy of Medical Sciences (2009) report Rejuvenating Ageing Research states that in the United Kingdom healthy life expectancy is increasing at least as quickly as overall life expectancy. Far fewer older people are disabled than was the case in the 1970s, and drug treatments for hypertension and cardiac problems have reduced the mortality from heart disease by 40% since the 1990s. Older people in many countries also contribute towards society in that they pay considerable tax and are major providers of care, both to children and to other older people. Nevertheless, the ageing of the population does result in higher health care costs. In most countries, people over 65 account for at least twice the health care expenditure that their proportion in the population would predict; in the United States, people over 65 constituted one-eighth of the population in 2000, but consumed nearly half of the health care expenditure (the UK figures were one-sixth and 43%, respectively). The OECD (1988) projection was that these figures for expenditure would rise to 63% for the United States and 54% for the United Kingdom, by 2040. Appleby (in Pilkington, 2009) estimates that the NHS needs about 1.5% extra funding every year just to cope with increased need due to demographic change.

The demand for health care

A second important factor in driving up health care costs is the growth of expensive medical interventions. Many medical innovations have not been fully assessed in terms of costs and benefits, although health technology assessment for potential new interventions is well established in Australia, Sweden, the Netherlands, the United Kingdom and the United States (in individual states such as Oregon, which was a pioneer in health technology assessment). In England, such assessment takes place through the National Institute for Health and Clinical Excellence (NICE). The costs of health technologies are assessed against the benefit, which is calculated primarily by means of quality-adjusted life years (QALYs). This measure has proved controversial; treatments for the terminal stages of diseases such as kidney cancer are likely to fall short of the threshold for NHS funding, since life expectancy is short, and in some instances QALYs have been recalculated to allow for this. Although NICE was set up to try to depoliticise decisions about expensive medical interventions, there has been intense lobbying in response to its decisions, and there is concern that services for other less vocal people, such as mentally ill or older people, may get displaced as a result. Arguments about the entitlement to treatment are likely to be tested in the courts, for example in 2006 in relation to Herceptin, a drug for certain types of breast cancer.

It has been recognised that a small percentage of people consume a large percentage of health care resources; therefore, managing LTCs has become an important element in health policy, both for humanitarian reasons and in an attempt to control costs. In England, one-third of the adult population has an LTC; in some areas this rises to half (Department of Health, 2008b). Even in younger age groups, 15% of children under 5 and 20% of children and young people aged 5–15 have an LTC (Wilson et al., 2005). The British Household Panel Survey (2001) found that people with LTCs accounted for 80% of GP consultations; they also account for 72% of inpatient days in England and 65% of outpatient appointments (Haddad et al., 20092009). By 2030, the incidence of LTCs in people over 65 is estimated to more than double (Department of Health, 2005b). People with long-term physical conditions also have a 20% risk of depression, a rate which is two to three times higher than that for people in good physical health (Egede, 2007).

Globally, the most common LTCs are cardiovascular diseases such as hypertension, coronary artery disease, stroke and heart failure, various forms of arthritis, respiratory problems, diabetes and epilepsy; such illnesses contribute to nearly half of the prevalence of disability worldwide. HIV/AIDS has also become an LTC in countries where there is adequate treatment. Mental health problems such as depression are also increasingly viewed as LTCs. LTCs are collectively the largest cause of death globally (World Health Organisation, 2005), despite the prevalence of infectious diseases in poorer countries; by 2025, an almost 300% increase in deaths from ischaemic heart disease and stroke is predicted in Latin America, the Middle East and sub-Saharan Africa (Yach et al., 2004). Chronic obstructive pulmonary disease is predicted to be the third main cause of death globally by 2020 (Murray and Lopez, 1997). About 2.8% of the global population has diabetes; this is likely to increase to 6.5% by 2030 (Murray and Lopez, 1996), and is linked to the increased incidence of obesity.

If current trends continue, 60% of men, 50% of women and 25% of children in the United Kingdom will be obese by 2050 (Foresight, 2007); excess weight is increasingly seen as the norm. It is beginning to be recognised in the United Kingdom that the environment is obesogenic, for example due to the availability of cheap, high-fat food, and that government intervention has not so far been effective; the chair of the International Obesity Task Force, Professor Philip James, gives the current English campaign, Change4Life, only a 10% chance of success (Dent, 2009). Change4Life is an example of a recent approach to addressing health-damaging behaviours which has been adopted from the United States, social marketing. A national centre for social marketing, a collaboration between the Department of Health and the National Consumer Council, was launched in 2006. The aim is not only to raise awareness but also to equip people with ways of changing their behaviour, using solutions which meet their needs, and where necessary, to change policies and structures which reduce people's capacity to live healthily.

As the example of obesity illustrates, reducing mortality and morbidity from LTCs requires individual engagement with lifestyle factors; Wanless (2002) has termed this the ‘fully engaged’ scenario, in which individuals take responsibility for their own health, and public health goals such as smoking cessation are achieved. If this scenario is not achieved, the costs of health care will become unaffordable. Public bodies also have a key public health role. High Quality Care for All (Department of Health, 2008a) refers to the legal duty for the NHS and local authorities to work together to address public health issues, and to cooperate in improving outcomes for their populations, on the basis of a formal assessment of people's needs (Joint Strategic Needs Assessment). These plans involve other agencies, such as the police, and focus not only on health priorities such as smoking but also on broader factors such as poor housing, education, local transport and recreational facilities.

Health inequalities

It has long been recognised that the risks of long-term health problems and premature death are not equally distributed in society throughout the developed world. Since the launch of the Black Report in England (Townsend et al., 1992), there has been considerable debate and research to understand the relationship between social inequalities and health. There are two broad categories of explanation for the causes of health inequalities. Cultural/behavioural explanations stress differences in lifestyles and may imply that such differences are matters of choice; such explanations can lead to ‘victim blaming’ for illnesses which are obviously lifestyle related. However, comparisons between people with similar habits such as smoking show that there are still differences in the effects of these habits between the social classes (Department of Health, 1998a), indicating that structural factors also apply. Structural explanations stress the role of social circumstances; for example, mothers in poorer families tend to feed their families cheaper, higher fat foods, and are also reluctant to cook unfamiliar food which might be refused and therefore wasted. Housing conditions are also a major determinant of health; people in poor-quality housing suffer more from depression and respiratory disease. During the years of Conservative government in the 1980s and 1990s, the structural causes of health inequalities were not acknowledged in policy, and in the mid-1990s, the term used by the Department of Health was ‘variations in health’ rather than health inequalities. The establishment of the Acheson Inquiry (Department of Health, 1998b) by the incoming Labour government was recognised as a significant break with previous policy. However, recognising the structural causes of ill health has not led to a reduction in health inequalities, as most recently demonstrated in the strategic review of health inequalities led by Sir Michael Marmot (Marmot Review, 2010).

The 2009 House of Commons Health Committee report on health inequalities co...

Table of contents

• Cover
• Series
• Title Page
• Copyright
• Foreword
• Notes on contributors
• Acknowledgements
• Introduction
• Chapter 1: Long-term conditions in perspective
• Chapter 2: Case management
• Chapter 3: Changing approaches to the management of long-term conditions
• Chapter 4: Sociological insights
• Chapter 5: Psychological effects of long-term conditions
• Chapter 6: Counselling skills
• Chapter 7: Living with long-term conditions: Tommy's story
• Chapter 8: Self-management and current health care policies
• Chapter 9: Managing common symptoms of long-term conditions
• Chapter 10: Medicines management
• Chapter 11: Management of heart failure
• Chapter 12: Management of respiratory disease
• Chapter 13: Management of diabetes
• Index