Case management of chronic diseases and long-term conditions: make haste slowly

chronic diseases is the main challenge for primary care, worldwide (Bodenheimer et al., 2002a). Individuals with long-term conditions consume a large proportion of health and social care resources, including 60% of hospital bed days in British hospitals (Department of Health, 2004), and 78% of all health care spending in the USA. It is estimated that 17.5 million adults in the UK are living with a chronic disease and that the incidence of chronic diseases and disabilities (long-term conditions) among those aged over 65 will double by 2030 (Department of Health, 2004; 2005). Clinical practitioners in Britain may be wary of systematic approaches to a whole population group like those with chronic conditions, given the failure of population screening for untreated morbidity in older people. Not only did the ‘75 and over checks’ introduced in 1990 have little discernable impact on the health of older people (Iliffe et al., 1999), but the recent Medical Research Council (MRC) trial of screening older people showed no benefits from such screening (Fletcher et al., 2004). Neither general practitioners nor specialists in care of older people performed well in the MRC trial, suggesting that medical management of problems revealed by screening is essentially ineffectual. Nevertheless, the belief that screening could prevent functional impairment in older people has had an enduring appeal to researchers, politicians, clinicians, and older people themselves, and the accumulating evidence against the value of whole population screening is not going to extinguish this enthusiasm for intervention. Nor should it, since there is some evidence from studies in the USA that targeted needs assessment of older people followed by active management may improve both survival and functional ability (Stuck et al., 2004). In North America comprehensive geriatric assessment with subsequent systematic management reduces hospital admission rates (Stuck et al., 1993), and models of chronic disease management have evolved (Bodenheimer et al., 2002b) to exploit this impact and contain care costs for an ageing population. Whole systems approaches in the USA,using case management methods (Wagner, 1998; Dixon et al., 2004), have been championed as a means of ensuring continuity of care, improving patient outcomes and achieving efficient management of resources (RCP et al., 2004; Department of Health, 2004; 2005). The core elements of any case management activity are: identification of individuals likely to benefit from case management, assessment of the individuals’ problems and need for services, care planning of activities and services to address the agreed needs, referral to and co-ordination of services and agencies to implement a care plan, and regular review, monitoring and consequent adaptation of the care plan. The National Health Service (NHS) is being encouraged to embark on a chronic disease management programme built around fostering selfmanagement, enhancing disease management in primary care, and introducing case management for individuals with complex problems who make high use of hospital services (Department of Health, 2004). The Royal Colleges of Physicians and of General Practitioners and the NHS Alliance have endorsed this programme and have made proposals for joint clinical directorates and clinical governance, across the specialist-generalist divide (RCP et al., 2004). Demonstration projects providing care across a spectrum of long-term conditions have developed (Matrix, 2004). In the UK nurses are seen as the professional discipline with the abilities to carry out and coordinate chronic disease management, and chronic Primary Health Care Research and Development 2006; 7: 185–187