Delivering person centred care in long term conditions.

Long term conditions are a major challenge to the sustainability of health services globally. Their increasing prevalence is associated with growing rates of preventable complications and premature mortality, resulting in soaring costs (box 1). These factors, coupled with higher expectations among patients and the public, create an urgent need to redesign health services, which are still largely geared to providing episodic acute care. 8 Definitions of long term conditions as “health problems that require ongoingmanagement over a period of years or decades” fail to reflect the personal, social, and economic burden on the individual, their families, and wider community. Nor do they acknowledge that people with long term conditions spend just a few hours a year interacting with clinicians and healthcare services and more than 99% of their lives managing their conditions themselves. The challenges they face vary widely depending on their personal circumstances; the number, nature, and stages of their conditions; the need for lifestyle, specialist, and technical interventions; and their capacity to self manage effectively. 11 Individual priorities and goals also differ and may often extend beyond a condition specific or health focus, particularly for the increasing percentage of people living with multimorbidity or frailty. It is widely agreed that person centred services for people with long term conditions should be coordinated; support self management; engage people in decisions; provide effective prevention, early diagnosis, and intervention; and offer emotional, psychological, and practical support. More needs to be done to realise the untapped potential of patient led care through increasing tailored information, education, and training; access to new technologies; and peer and community support. 13 Accumulating evidence and experience shows that people who are “activated”—that is, have the knowledge, skills, and confidence to manage their health effectively—are more likely to adopt healthy behaviours and have better health outcomes and care experiences.This may lead to better use of resources. Thus, health services need to provide a comprehensive and coordinated range of interventions for populations but organised to provide a tailored response for each person. This requires fundamentally newways of thinking about service delivery and relationships, recognising that whole system approaches are needed with support for self management as the central component, as set out in the chronic care model. Recent comprehensive programmes of care, such as TEAMcare in the United States and the Flinders programme in Australia, show that system wide organisational change can be achieved and improve clinical and personal outcomes. Challenges and barriers