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Health policy review

Summer 2006

Issue 2: Different approaches to reforming health services

Improving the management of long-term conditions in the face of system reform - Helena McKeown, Tom Smith, Helen Smith and Eleanor Babbington

• Introduction
• Who is best placed to commission effective long-term care?
• How can the professionals who provide long-term care overcome the barriers between them?
• How can the healthcare system best support patients’ ability to manage their own care?
• Can a culture of collaboration be achieved in the face of competition?
• Conclusions

Introduction
An estimated 17.5 million adults in the UK live with a long-term condition [go to note 14]. Long-term conditions account for a high proportion of NHS time and resources [It is estimated that around 80 per cent of GP consultations relate to longterm conditions as well as over 60 per cent of hospital bed days]. There is an increasing view, as well as evidence to support it [Hutt R, Rosen R & McCauley J (2005) What impact does it have in the treatment of other older people? London: King’s Fund], that changing the way resources are directed could save money in the long-term by keeping people well and avoiding the need for clinical care.

A number of policies provide a conceptual framework to guide the recent shift in focus. While research provides support for the overall approach there is a need to adapt these approaches to different contexts and individual needs.

The thinking process that local clinicians and managers need to go through to develop implementation, has been disturbed by a revolutionary and rapidly changing policy context. Plurality and payment by results make implementation more uncertain, a situation that is further complicated by the structural reconfiguration changing the shape of primary care.

The white paper, Our health, our care, our say [Department of Health (2006) Our health, our care, our say: a new direction for community services. London: HM Government] has reiterated the ambition to improve the management of long-term conditions, it also highlights key priorities in taking this agenda forward both nationally and locally.

The aim of this paper is to attempt to make sense of proposals to improve the health of those living with long-term conditions in the face of system reform. It begins by outlining the framework of policy and setting out some challenges and opportunities. It then goes on to consider four key questions pivotal to effective implementation:

• who is best placed to commission effective pathways for those living with long-term conditions?
• how can the professionals who are integral to long-term care best negotiate the barriers between them?
• in what ways can the healthcare system best support individuals’ capacity to better manage their own health?
• how can a culture of collaboration be achieved in the face of competition?

Policy framework to improve management of long-term conditions
In March 2004, the then secretary of state, John Reid, set out three key priorities; disease management, case management and self-care [go to note 15]. Disease management monitors at-risk populations and intervenes early to meet needs, case management identifies vulnerable individuals and builds care around them and self-care aims to help individuals and carers develop the knowledge, skills and confidence they need to better manage their own conditions. In line with these aims, the government has introduced a Public Service Agreement target to reduce inpatient emergency bed days by 5 per cent. Disease management, case management and self-care are all seen as key levers to achieve this.

The Department of Health has recently represented as a triangle, the complexity of its policy aims for more proactive management of longterm conditions (figure 2) [go to note 16]. At the top of the triangle are those with complex needs who require specialist interventions. In the middle are those whose care can be managed from a distance. A key goal is to prevent people in the middle moving upwards towards the top tier.

Figure 2: Complexity of Department of Health policy aims


























In the white paper, Our health, our care, our say the triangle (figure 2) is used to illustrate the point that for the majority of conditions self-care and shared-care could improve health status, without the need for high-end clinical interventions. There are, however, questions about how effective such initiatives will be in reducing emergency admissions because it is difficult to relate outcomes to interventions [go to note 17].

Pilot initiatives in England have suggested that schemes may need to be tailored to our NHS and English context, in order to be fully effective, which is different from service provision in the USA [go to note 18]. Primary care trusts (PCTs) need flexibility to develop their own arrangements to improve care for patients with long-term conditions and the onus will be on developing local solutions based on the principles outlined.

The context is changing
Since policy proposals for managing long-term conditions were published, policy in other areas has moved forward. Payment by results, a new financial system has developed new incentives, the consequences of which may be difficult to predict. By supporting new entrants to healthcare it is likely that new non-NHS providers, for example the voluntary sector, may in the future provide acute, community and primary care. The future structure of healthcare provision is therefore likely to change.

The policy picture is becoming increasingly complex. David Pink, chair of the Long Term Medical Conditions Alliance (LMCA) comments: ‘the focus on long-term conditions is in danger of sinking without a trace because there are so many other priorities’ [go to note 19]. The complexity and size of system reform make it difficult to connect policy and make sense of plans to improve the management of long-term conditions.

Difficulties of implementation
The white paper, 'Our health, our care, our say' develops thinking around the management of long-term conditions in the context of system reform. The challenges of changing the system are not straightforward. There are barriers between social care and healthcare from different eligibility criteria, decision makers, commissioners and providers. These barriers result in discharge problems and cultural differences, which are not easily overcome. There are also two further key problems, which are related. The first is that incentives are not well aligned between different parts of the system, and the second that there are gaps in the system that patients risk falling through.

Incentives do not point in the same direction
The white paper, 'Our health, our care, our say' encourages ‘health partners to work across the health economy thinking as a health system’. Incentives are not well aligned between organisations and there are questions about whether current incentives will enable the necessary movement of care from secondary to community settings [go to note 20]. There are also concerns about how the culture of competition between providers and between primary and secondary sectors will develop in the future especially with further policy initiatives.

The white paper proposes that more care provided in community settings should ease the pressure of demand on the NHS. This aim could be overshadowed by payment by results in the acute sector, which is in its early form of implementation beginning in April 2006, and which may produce incentives to drive the acute sector in the opposite direction, therefore encouraging more treatment [Toynbee P (3.2.06) Forget the high concepts, this is an ideal prescription for the NHS. The Guardian]. System reform deliberately generates tensions between the acute and nonacute sectors. Without better alignment it is likely that the two sectors will compete. The NHS is a system and if resources are concentrated in one place they must be drawn from another. Making effective use of an integrated framework will require cross sector system thinking.

Boundaries between groups
There are questions about how new roles, such as community matrons, will fit into professional teams and relate to clinical networks. A key part of the review of system reform should be the future workforce and how new roles are integrated into local healthcare provision. There is potential for changes in all healthcare sectors to strengthen healthcare delivery.

Integration of policies to improve long-term care
With no clear explanation of how the many different policies will be put together there is a clear onus on local managers and clinicians to work with providers and patients to develop services. The following sections look at how policy might be taken forward.

a) Who is best placed to commission effective long-term care?
At the population level, until now, commissioning care for those with long-term conditions has been by directors of social care in local authorities and directors of commissioning in PCTs. This has been a barrier to comprehensive care, creating a division between the medical and social support needed by those living with long-term conditions. The white paper aims to achieve joined-up commissioning by focusing anew on the relationship between directors of adult social care and directors of public health.

The white paper talks positively about the potential for further tailoring care to individual needs, through the development of practice-based commissioning and the devolution of commissioning to groups of GPs. Groups of GPs are thought to be better placed to commission because they have the advantage of knowing their patients and the context of their circumstances.

The white paper also outlines how the Department of Health might sponsor work to develop and disseminate good practice models of commissioning for people with long-term conditions. This ‘good practice’ will follow from the early experience of local groups.

Coherence is needed between the different levels of commissioning
Policymakers, doctors and managers in England and in Scotland recognise that the current configuration of services is not an ideal one and each aim to alter patterns of service accordingly. In Scotland the focus is on the use of networks and partnerships, with existing and new primary and secondary care organisations working together with allied professions to deliver the service. In England however, the focus is on market forces and associated financial incentives to provide efficient services through competition and a separation of commissioning and provision. Scotland is aiming to forge united health systems, breaking down structural barriers.

The emphasis has been placed on improving commissioning, but there remains uncertainty over how different levels of commissioning will be balanced, including the allocation of indicative and real budgets to practice-based commissioners.

National contracts have been awarded to independent providers and the voluntary sector.

• Social care is commissioned by the local authority.
• The newly amalgamated PCTs are to concentrate on their commissioning function across larger areas.
• Practice-based commissioning will see a proportion of the commissioning budget being given to GPs to directly commission services. GPs will also directly provide many of the services needed.
• Commissioning GPs will have the opportunity to commission expanded practice based primary care teams, more specialist clinics in the community, and enhanced care services for those with longterm conditions.
• Social care budgets will be extended for eligible individuals.

Close coordination is needed between the different levels of commissioning to align strategic decisions across the health economy and bring together policy strands locally. This does not only relate to the funding of healthcare, but also to transport, community day places, housing and other forms of support that are critical to improving care.

A way of thinking about commissioning across different levels is conceptualised in figure 3 [go to note 21]. The aim of the process is to develop individual care packages and to provide cross-boundary services so that people with long-term conditions do not require care in the outer circle ie in hospitals, nursing and care homes. Providing coherent services that achieve this will mean negotiating service and strategic development between local commissioners, providers and professionals.

Figure 3: Aligning commissioning

























Better alignment between local authorities and PCTs
The recent white paper, Our health, our care, our say comments that there will be ‘a new partnership between local authorities and reformed PCTs.

A key problem in the care of patients with long-term conditions is the complexity in the relationship between social and healthcare. There are difficult management and financial issues. Social care is managed and financed separately from healthcare by local authorities. The financial complexities arise because healthcare is free but personal care in England is not.

In the absence of joint funding, better management is needed. As the white paper 'Our health, our care, our say' notes, one of the main concerns of patients is the poor coordination between health and social care; the plan to develop joint care plans is therefore welcomed.

Disease management and the need for a population view
There needs to be a sensible balance between an individual’s case management and a population based disease management approach. Personalised and individual care is ideally designed in partnership, focusing on continuity of care and the special relationship between an individual with a long-term condition and their GP. Potentially, NHS GPs as commissioners and working with directors of public health, have the ability to balance the individual’s case management and a population-based disease management approach to make best use of NHS resources. Complex cases can be managed effectively in primary care and this will become increasingly the case, as complex care packages can be developed and commissioned to address individual patient needs that span both primary and secondary care.

In focusing on long-term care, public health should be closely located to the commissioning function, supporting PCTs and providing a resource for commissioning groups. Public health has a key role to play in improving demand management, providing intelligent epidemiology and aiding disease management. Public health can help to provide analytical capacity that is needed to identify people at high-risk of admissions and support commissioning.

Local bodies need to come together to develop disease-based protocols that will help strengthen system integration. They can develop solutions based on clear principles: identifying people with complex single needs and multiple conditions, using GPs’ in-depth knowledge of patients and their individual circumstances and building on existing primary care teams’ knowledge of those with long-term conditions, as well as disease-specific protocols and pathways, such as the National Service Frameworks and Quality and Outcomes Framework [Go to note 22]. There is a need for these protocols to be clarified locally, as different approaches can sometimes conflict. This process can be a useful way of bringing different perspectives together to examine the system of care. It is important that local initiatives are clearly evaluated. This will inform learning and adaptation of programmes. It will also help to spread best practice. Critically important to this is the clear identification of measurements, which will ensure their validity.

Practice-based commissioning
In England, one potential positive is the development of practicebased commissioning (PBC) which may provide a mechanism to alter patterns of service provision and more local care, but there are questions about how it will work. In Scotland the framework for how local pathways will be formed is clearer than in England.

There is potential for PBC to become a force for cohesion by mapping care routes and developing collaboration. PBC could also help begin to move services from hospitals into the community. There is evidence that GP fundholding in some areas did reduce hospital admissions [go to note 23].

A key challenge for commissioners will be to ensure that services are well coordinated and care is seamless, while commissioning decisions must be agreed with PCTs who are obliged to support the policy drive to offer choice. PBC offers some exciting opportunities for doctors in primary care to work with others to create new care pathways (an issue discussed in more detail in the final section).

b) How can the professionals who provide long-term care overcome the barriers between them?
Over the last few years professionals working in this sector have been moved regularly between organisations with different names, other than in general practice, which has remained constant. It is important that change in PCTs does not undermine this approach. An important (and unquantified) cost of continuous reform is that relationships are undone and have to be reconstructed with each change. When implementing change, care must be taken to sustain and progress relationships between professionals.

Uncertainty over the future structure of health outside hospitals
While there is a clear need for effective links between professionals providing care and advice to patients, at present there is a great deal of uncertainty about organisational structures outside of secondary care.

The English policy on caring for people with long-term conditions [go to note 24] emphasised the need to embed into local health and social care communities an effective, systematic approach to the care and management of patients with a long-term condition. To reduce the reliance on secondary care services and increase the provision of care in a primary, community or home environment. The proposals include a personalised care plan for vulnerable people most at risk and reducing emergency bed days for people with long-term conditions by 5 per cent by 2008.

A paper entitled Commissioning a patient-led NHS was sent by the NHS chief executive to all strategic health authorities at the end of July 2005. It said that PCTs should concentrate on commissioning and only provide ‘as a last resort’ [go to note 25]. PCTs are significant providers of community care and the professionals they employ are central figures in the networks of professionals dealing with patients living with long-term conditions.

Linking professionals
Delivering for Health advocates the development of an NHS that is ‘as local as possible’. This recognises that hospitals provide increasingly specialised care, but also aims to develop a greater capacity for treatment outside of hospitals. A number of proposals included in the report are intended to work together to achieve this aim.

One of the major problems in addressing the needs of those with long-term care is the fragmentation that exists between different professionals, located within different organisations. Continuity of care depends upon clear relationships between professionals. An important vehicle for this is achieving the single joint-assessment of needs between health and social care, as part of case management. From this should follow the production of a care plan with individuals that can be followed by each.

A review of evidence on chronic care has found that ‘linking the care provided by family doctors, hospitals and community groups and using teams of different professions improves quality of care, systems and costs’ [go to note 26]. Wherever professionals are based there needs to be incentives, structures and a clear rationale for strong relationships between them. Currently, managers with budgetary constraints and limited numbers of personnel are forced to manage their financial constraints by drawing out staff who were traditionally integrated into primary care teams. This has had a detrimental affect on communication and continuity of care thus undermining the vision of increased care closer to home.

Policy is based on the premise that in most cases support for patients will be provided by multidisciplinary teams based across primary and community services (with support from specialist services). Clinical networks provide a basis on which to develop local condition-specific services.

Innovations in care
PBC offers the opportunity for groups of GPs to build networks of professionals providing new services to which they can refer. There is a variety of ways in which this can be done and the precise shape of the ‘team’ will vary by location. Different professionals could be brought together in critical care teams, for example, providing community support to rapidly changing personal circumstances.

Although community professionals have always striven to prevent hospital attendance, it is now government stated policy that the overarching aim for the health system will be to keep people who can be treated elsewhere out of hospitals. We may see more care taking place away from the acute sector and examples of collaboration between secondary, community and primary care clinicians. There could be many more clinics providing secondary care in the community, staffed by nurses and others working with hospitals consultants and/or GPs with special interest in particular conditions. The recent white paper sees a particular role for community hospitals in providing local care and blurring traditional boundaries between primary and secondary care.

Developing local approaches to case management
There is no single model of ‘case management’ and approaches vary. Health communities need to find a forum in which professions can consider how to provide a case management service across the whole health economy. Most GP practices already hold regular primary care team meetings where colleagues draw on their longstanding patient knowledge to identify those most likely to benefit from support whose membership and function can be expanded to develop a local approach to case management. An advantage Scotland may have over England is a more coordinated approach to case management because of the creation of structures and teams to support it. If successful, monitoring and proactively caring for some groups could reduce health inequalities in important ways.

In current policy, the new role of ‘community matron’ needs to be carefully thought through. Changing skill-mix is essential to policy and there have been announcements about extending the roles of non medically qualified practitioners. Community matrons, supported by district nurses and their equivalents, will have responsibility for high-risk patients. In practice many patients who are managed in primary care by GPs usually have co-morbidity, thus necessitating strong links within and between teams. It is important that these new roles are developed coherently and are strategically linked to current systems, rather than working parallel or, even worse, in opposition to them. There are concerns that the roles will work in isolation of existing primary health teams, to the detriment of patients and that community matrons will be recruited from existing district nursing teams, which will then be depleted.

Linking with primary care health teams (PCHTs)
The PCHT provides an ideal structure to permit frequent face-to-face exchange, in formal and ad hoc ways. General practice can be the hub for information exchange to inform clinical strategies and play a coordinating role, by holding information from different professional perspectives, including knowledge about an individual’s extended family, work and social circumstances. Patients with chronic diseases need personalised care, which will be more effective if linked to a local practice with care delivered by people they know, who have the ability to monitor them in their own environment.

PBC is potentially a vehicle to bring together a strengthened primary care health team by further investment that is better integrated into community structures.

c) How can the healthcare system best support patients’ ability to manage their own care?
Like case management and disease management, there is no single approach to self management and it varies by individual. Individuals have different reactions to diagnosis and different ways of coping. Patients want different kinds of support and professionals need to help ascertain how this is best developed. Some might need more flexible ways of accessing support, others might require stronger one on one contact with a health professional and some need better signposting.

A publication from the King’s Fund, looking at patient perspectives on long-term conditions, identified three key contributors to success: good relationships between professionals and patients; clear information on conditions and how to access services; and more flexibility in service provision [go to note 27].

Innovations in service
Effective case management will mean patients having rapid access to care and this will involve strengthening relationships between different professionals.

GPs are traditionally described as gatekeepers because they are the route to secondary sector. The evolution of this role from gatekeeper to a single secondary care pathway, into navigator to many, potentially confusing, pathways, will be even more important because hospitals will face incentives to generate more income by drawing in more patients. GPs as navigators of the healthcare systems will become increasingly important, especially in using their new commissioning powers to innovate and to provide access to new services for those with long-term conditions.

Better information
Many patients do not know where to go to access services. Early findings from the Your Health, Your Care, Your Say consultation suggest that people want better information on what services are available and how to access them [go to note 28]. Essentially, better signposting is needed. Reducing inequalities is an explicit aim of the Scottish proposals. Delivering for Health includes a number of proposals that work together to achieve this, including providing deprived communities with enhanced primary care teams with resources to identify 'at risk' populations and providing early access to preventative interventions.

In England the target is to improve the health of the population: increasing life expectancy at birth in England to 78.6 years for men and 82.5 years for women by 2010. The white paper Choosing Health [go to note 29] proposes that providers of local health services are helped to tailor information and advice to meet people’s needs. Provision of support staff to communicate complex health information to different groups in the population and practical support for people who lack basic skills to help them use health information including signposting them to extra support though programmes such as skilled for health, are also proposed.

A recent BMA discussion paper on the Expert Patient Programme (EPP) is very supportive of the approach and the potential for the model to develop. One concern, however, is that the more assertive middle-class may disproportionately benefit from the initiative. More work is needed to evaluate ways to involve hard-to-reach groups. PCTs should be encouraged to increase provision of and GPs should be encouraged to refer to the EPPs and referral routes to the scheme need to be developed from secondary care. If the programme becomes a mainstream model, as it should, there is potential for the framework to be developed and more programmes initiated that are perhaps tailored to a particular section of the community. GPs with a special interest in the management of long-term conditions could follow the EPP programmes, learn from them, and help develop the model.

Developing patient-clinician relationships
Part of the rationale for the introduction of the choice reforms is a stated wish to give patients more power in the consulting room. One benefit of empowering patients is that they co-design their care plan and are therefore more likely to become active participants in decision making and in managing their own health.

Improving the management of long-term conditions will involve ways to enhance the time made available to those who need it. This might be achieved either through the commissioning of dedicated teams through groups of practice-based commissioners or by increasing the members of existing primary care teams, perhaps by bringing in social workers or developing the role of ‘link workers’ with both health and social care skills. Continuity is vitally important to patients and one way of improving the quality of care given by an individual GP is by developing the enhanced roles played by other professionals in a coordinated team and following a single care plan agreed with each patient.

d) Can a culture of collaboration be achieved in the face of competition?
The King’s Fund case study of incentives in a London health economy [go to note 30] found that local managers feel that ‘new policies, especially payment by results and the establishment of foundation trusts, are seen to be reinforcing the boundaries between institutions and hindering the collaboration needed for seamless patient care’. There is potential for destructive tensions and there is a critical need to ensure collaboration, which will require local bodies to develop incentives to ensure joint-working.

Managing a market
A deliberate tension within payment by results is the conflict of interest between primary care and secondary care. While each will face positive incentives to draw patients towards their services, this creative tension could be overshadowed by more destructive ones if they engage in a ‘tug of war’ over patients and the payment which follows them.

Establishing pathways to guide patients across tertiary, secondary, community and primary care will require discussions across health economies. A major challenge in the near future is how best to work across the traditional barriers of primary and secondary care. Rather than integration being driven by a defensive response, seeking to colonise the traditional territory of the other, there are opportunities to develop cross-boundary collaboration by establishing or resurrecting clinical networks.

It is not yet clear what ‘managing a market’ means for a local commissioning authority. To ensure gains for patients, the starting point for PCTs should be to plan care pathways and the key points on a patient’s journey. Providers could then compete for contracts to provide all or some of these stages. This approach may allow patients to choose different pathways without fear of fragmented care. The concept of a patient journey is meaningful to both patients, professionals and commissioners and provides a clear focus for measuring patient satisfaction with their experience of different parts of care and a way of commissioners focusing on service improvement.

Commissioning cross-boundary care pathways
A care pathway is a phrase employed to capture the design of a care management system for a clinical condition that involves identifying required interventions and setting out the various stages of care through which a patient passes. The approach aims to create smoother journeys through the healthcare system by coordinating care across different sectors and settings. In developing these, there is potential to expand and build on existing clinical networks.

Patients should be able to move between different pathways of care across a network of providers, which will allow choice of treatment. Choice for those living with long-term conditions will not be the same as choice in elective care because the necessity for continuity and whole-systems working is so important. There should also be systems in place to allow for appropriate care of patients who do not necessarily need hospital care but who are not well enough for home care and vice versa. The expansion of step up and step down facilities both in and between care providers would greatly facilitate care but this relies strongly on the commissioning of appropriate care across care boundaries.

Although Scotland is likely to make more use of the independent sector, the involvement of the private sector is targeted at areas where there is under-capacity. In England, private sector involvement is considered to be core to a principle of ‘contestability’, which is absent from Scottish plans.

Collaborative working in England is, in a sense, made counter culture by recent reforms. In the face of competition and payment by results’ incentives to maximise treatment, providers face incentives to deliver as much care as they can. This means volume, but also breadth. There are few incentives for the kind of joint-working that would be needed to reduce length-of-stay in a hospital and enhance the care that a community provider might bring. The onus for collaboration will be on creating joined-up pathways from competing providers. The need to develop the commissioning function is highlighted in recent policy. In England, collaborative mechanisms that emerge may come from entrepreneurial groups of GPs commissioning pathways. They will face challenges in drawing hospital doctors out into community settings because in doing so a doctor may act against the commercial interests of his employer, which is to bring cases into hospital.

Unbundling and bundling – paving the way for care pathways
It is not the intention of this paper to address technical issues, but one that cannot be ignored is unbundling. If pathways are to cross institutional boundaries, there is a need to take the current tariffs within payment by results and first break them down (unbundling) and then reconstruct them in different ways (bundling) to form care pathways.

There is a pledge in the white paper, Our health, our care, our say, to examine the unbundling of payments. This is vital if ambitions to provide more care in community settings are to be achieved. At present however, the payment by results system pays providers for a block of care in relation to a particular treatment. The payment incorporates a variety of components such as tests, interventions, rehabilitation and so on. There is discussion about whether payment blocks can be broken up so that components could be provided in different settings.

Unbundling would mean making the cost of each component of care transparent. This process would allow different organisations to be paid for carrying out different parts of the treatment. The tariff payment could then be apportioned in different ways according to preferences. Different providers to work together to rebundle care in different packages and new care pathways could be tailored to support better integrated care. If the costs of treatment could be unbundled, it would be possible to develop flexible pathways that would afford choice of provider at different stages.

Conclusions
This paper supports aims to improve the care of those living with long-term conditions. It notes that the myriad of policy, known as system reform, makes these aims more difficult to achieve. Perhaps the major challenge in improving the management of longterm conditions is in the redeployment of resources, human and financial, in health and social care. In the five years since the NHS plan was published, it could be argued that policy in England has become less clear. Subsequent changes to the financing of healthcare, the introduction of a range of powerful new incentives and a greater than anticipated role for the independent sector have left many confused about the clarity of the English policy agenda. Elderly patients, in particular, are frequently admitted not because of a medical problem but through a lack of social and domestic support. Unless this is tackled, it will remain a key barrier to improving the lives and clinical management of those living with long-term conditions. Since the question increasingly for doctors is, how can we harness these changes to achieve some overarching policy aims that we support – improve care for those living with long-term conditions, and more effective working across the secondary and primary care sectors. New forms of organisations are beginning to emerge that may allow service innovations for example, ones that may involve professionals leaving NHS employment [go to note 31]. Some are enthused that these approaches offer opportunities for clinicians to lead service innovations.

The implementation of policy to improve the care of those living with long-term conditions is complicated by a rapidly changing environment. Different strands of policy are discrete and not well connected. There needs to be a whole systems approach to delivering care for those with long-term illnesses and for this to place the patient at the centre of the care pathway. This should be developed through policy or implementation strategies.