Disease Management

The increased incidence of chronic diseases and conditions [2] presents a huge challenge not just to the NHS but worldwide. Chronic diseases are those that can only be controlled and not, at present, cured. They include, asthma, arthritis, cancer, chronic obstructive pulmonary disease, diabetes, heart failure, dementia and a range of disabling neurological conditions.

Living with a chronic disease has a significant impact on a person’s quality of life and on their family. The incidence of such diseases increases with age. Many older people are living with more than one chronic condition and this means that they face particular challenges, both medical and social.

The care of people with chronic conditions also consumes a large proportion of health and social care resources. People with chronic conditions are significantly more likely to see their GP (accounting for about 80% of GP consultations), to be admitted as inpatients, and to use more inpatient days than those without such conditions.

What makes for good chronic disease management?

There is growing evidence, from service improvements, initiatives already in place and the experience of other countries, that the essential components of good chronic disease management include:

Use of information systems to access key data on individuals and populations
Identifying patients with chronic disease
Stratifying patients by risk
Involving patients in their own care
Co-ordinating care (using case-managers)
Using multidisciplinary teams
Integrating specialist and generalist expertise
Integrating care across organisational boundaries
Aiming to minimise unnecessary vists and admissions
Providing care in the least intensive setting

Effective chronic disease management can make a real difference, helping to prevent crises and deterioration, and enabling people living with chronic conditions to attain the best possible quality of life.

[1] World Health Organization (WHO) Noncommunicable diseases Action Plan www.who.int
[2] The terms chronic disease, chronic condition, life-long disease/condition, long-term disease / condition and non-communicable disease/condition are commonly all used interchangeably


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