Chronic Disease Management

Practice Leads

  • Doctors: Liz Hamblin
  • Nurse: Zoe Booth

Date Reviewed

14 April 2016

Date of Next Review

September 2017

Why managing chronic disease is important

There is a growing epidemic of chronic disease in the UK due to tobacco use, unhealthy diets, physical inactivity and other risk factors.   Whilst it is important to prevent these diseases from happening in the first place (which we are also trying to do - termed 'primary prevention'), it is also important to prevent them from getting worse or causing other problems in patients who already have them (this is called 'secondary prevention').  With good management of chronic diseases, people can live longer.

A good example of this is diabetes - if you don't manage a patient with diabetes properly, their diabetes will get worse, and over a number of years, they may end up with kidney failure, blindness, heart attacks, strokes, gangrene of the legs and so on.  And then they end up being hospitalised.   If we treat a patient's diabetes and get their sugars under good control, we can stop them from getting most of these things and reduce unnecessary hospitalisation.  Clearly, this is very good news for the patient (as it stops their lives from being hampered by illness, infirmity and disability) but it's also good for the NHS in general because the cost of treating these  complications and subsequent hospitalisation would otherwise be very expensive.

Offering good co-ordinated care that is in line with national and local guidance reduces the fragmentation of care and also reduces the risk of clinical error (including medication errors) and thus litigation risk.  In summary, by optimising the management of a patient's chronic disease, EVERYONE is a winner.

This drawing is from a lady with a long term condition (LTC).  The green line is her managing her chronic (long-term) condition.   The red bars indicate the times when she has to make contact with a health professional/service.   As you can see, this patient is an expert of her condition and she manages her condition on a day-to-day basis by herself.   It's important that her health professionals support her when things are a bit rough (the red bars) and help her get back to the more stable green line.     But we can only do this with patients if we invest time in them by....

  1. educating them about their illness(es)  (filling in the gaps in their technical knowledge)
  2. giving them confidence with self-management
  3. facilitating shared decision making.

If we don't do this, then we simply create dependancy on us (which in turn creates unnecessary pressure on GP and hospital services) but more importantly it is ethically unfair on patients because it limits THEIR freedom and THEIR choice about THEIR own lives.   Would you feel happy if this was taken away from you?

patient with a chonic disease

What are we aiming for? (The 4 stages of Care Planning)