Prevention, integration and implementation: healthcare leaders’ views on the major conditions strategy
Key points
- NHS leaders have identified key levers that the major conditions strategy can use to maximise its impact on healthy life expectancy and reduce inequalities. These fall under three categories: create a healthy society; make the most of existing infrastructure and policy; and implementation.
- The major conditions strategy will allow health services to evolve from a single-disease approach to a multimorbidity approach, which will match how patients need to use the service.
- Integrated care systems will provide vital infrastructure for the sharing of data, integration of services and creation of a patient-centred approach to health and care provision.
- A health service designed around multimorbidity would be a step-change for patients and requires a series of shifts to be made in both focus and provision.
What is the major conditions strategy?
The major conditions strategy is a national framework being developed by the Department of Health and Social Care (DHSC) and the Office for Health Improvement and Disparities (OHID). It will:
- focus on six major groups of conditions: cancers; cardiovascular diseases, including stroke and diabetes; chronic respiratory diseases; dementia; mental ill health; and musculoskeletal disorders
- cover the whole care pathway from prevention to treatment, including the role of innovation to improve outcomes
- take forward the Levelling Up health mission to narrow the gap in healthy life expectancy by 2030, and increase healthy life expectancy by 2035
- alleviate pressure on the health system
- reduce ill-health related labour market inactivity.
The strategy is an opportunity to reframe how we address illness in England. Until now, services have been designed around individual disease conditions, but this no longer reflects how patients interact with the health service. More than a quarter of the adult population in England live with two or more long-term conditions (known as multimorbidity). These patients are the country’s highest users of health and social care services and experience the most unplanned admissions and outpatient care. One-third of all patients admitted to hospital have five or more health conditions. But because services have been set up to deal with single conditions, people living with multimorbidity and their carers have to spend a vast amount of time and energy accessing different services, complying with multiple complex treatment plans and coordinating care. This is known as ‘treatment burden’ and affects patients’ quality of life by reducing their ability to rest, work, and spend time with loved ones. There are also persistent inequalities in the burden of multimorbidity. For example, patients from the most deprived areas in Scotland develop multimorbidity ten to 15 years earlier than patients in the least deprived areas.
Reducing the impact that multimorbidity has on people’s lives is an opportunity where system-level change could transform both quality of life and the economy
The six major conditions have been selected due to their impact on premature mortality and reduced healthy life expectancy, as they account for 60 per cent of disability adjusted life years (DALYs) in the UK. They have likely also been chosen because of their impact on people’s ability to gain and retain employment: mental health and musculoskeletal disorders are the most common reasons for sickness absence in the UK. Research on the impact of multimorbidity has shown that in working-age adults, multimorbidity reduces productivity and can increase the chance of absenteeism, early retirement, unemployment, and periods of recurrent leave from work. Across the system, this means that multimorbidity has a stark effect on economic participation. Reducing the impact that multimorbidity has on people’s lives is an opportunity where system-level change could transform both quality of life and the economy.
The major conditions strategy is consolidating several condition-specific strategies that had been expected, including the ten-year plan for mental health and wellbeing and the cancer plan, as well as the health disparities white paper. The NHS Confederation’s Mental Health Network responded to the consultation on the mental health and wellbeing plan. We also published a report, Moving From Silos to System Improvement, for the DHSC to consider within the health disparities white paper, based on engagement with the NHS Confederation’s networks. The DHSC has committed to using submissions from the last year’s calls for evidence in cancer and mental health to inform this work.
Why do we need a multiple conditions approach?
An integrated approach to the major conditions will mark a step-change in how patients experience the health service, by designing long-term condition management around the patient rather than by condition or pathways. It will require engagement between professionals and patients that empowers individuals and facilitates shared decision-making. Pilot applications of integrated multimorbidity care models have shown improvement in quality of care from both patients’ and health care professionals’ perspectives.
"70 per cent of the people on our mental health community caseload are also on our community physical health caseload. We could do something radically better for patients with a multimorbidity approach, and radically better for staff, and improve outcomes." NHS Foundation Trust Chief Executive.
Integrated care systems will be crucial in delivering on the aims of the major conditions strategy. One year on from their formal establishment, the ICS infrastructure brings together community, primary and secondary care services with local government and the voluntary sector: the whole ecosystem. Through this infrastructure, multiple-condition care can be developed and co-ordinated more effectively. Innovative, personalised care pathways are being created between different providers, informed by integrated data sets and population health management tools, that segment and risk-stratify populations.
View from health and care leaders
The NHS Confederation convened two member roundtables with the major conditions strategy teams from the DHSC and OHID, for local health and care leaders from across the system to voice their views on the potential of the strategy and inform its interim report.
Health and care leaders identified three key themes to be considered in the strategy and nine levers that the strategy can use to enable it to succeed in its aims to shift to integrated, whole-person care, and narrow the healthy life expectancy gap.
The table below summarises the themes and levers, as well as recommendations on how the levers can be actioned.
The levers needed to succeed
Create a healthy society
1. Prevention through regulation
“Primary prevention needs to be reflected in the strategy. Some of these major conditions are preventable, and aligning this from a population health perspective will be key.” ICB Chief Executive, North East and Yorkshire.
“This harm isn’t because people haven’t displayed sufficient personal responsibility, but because we inhabit an environment where it’s cheap, easily accessible and heavily advertised. This is the business end of non-communicable disease prevention.” Director of Public Health, North East and Yorkshire.
One of the strategy’s aims is to narrow the healthy life expectancy gap. To do this, it must use the central levers at its disposal to address growing ill health in communities.
Given that obesity and tobacco are linked to all of the major conditions, preventing these drivers of disease cannot fall only on the state or on the individual. Government regulation through taxes and levies make the healthy choice the easier choice for everyone. These taxes/levies do not have to be directed at consumers but rather can be targeted to the commercial entities (commercial determinants of health) profiting from products that can be associated with health problems for which the public purse pays the price. Tobacco costs the NHS in England £2.6 billion pounds per year, and wider society around £17 billion per year. The UK tobacco market makes profits of over £1 billion per year, even factoring in the tobacco duties that they currently pay. Obesity, the other highest cause of preventable illness and death in the country, is estimated to cost the UK £9.7 billion per year.
The Khan Review, Making Smoking Obsolete, and the National Food Strategy part two both suggested employing regulatory levers: a polluter-pays levy whereby stop-smoking services are funded by additional taxation on tobacco companies; and a salt and sugar reformulation tax, on salt and sugar sold for use in processed foods or in restaurants and catering businesses. Some of the revenue from the sugar and salt reformulation tax could then be spent on providing low-income families with fresh fruit and vegetables - something increasingly important given the impact of the rising cost of living on food insecurity and access to nutritious foods. If the government is serious about reducing the gap in healthy life expectancy, and preventing onset of the major conditions, regulating the markets for harmful products will be crucial.
2. Address structural factors such as racism, poverty and gender inequality which drive inequalities in the conditions
“We know that women often present later in the cardiovascular disease pathway and with different symptoms to men. This means that they have delayed start to treatment and variable outcomes. The strategy needs to look at the deficits in the current pathways in terms of outcomes for different groups of people.” ICB Chief Executive, North East and Yorkshire.
“When we think about prevention, and tackling ‘lifestyle behaviours’ such as healthy eating, there is a whole cohort of the population who can’t engage in these conversations because they are too worried about how they will get through each day. Our local food bank no longer provides tinned food because people can’t heat it up.” NHS Trust Place Leader, West Midlands.
The strategy is also intended to alleviate pressure on the health system. This will require a shift from treating illness, to preventing its occurrence. To do this, the strategy must address the risk factors for the major conditions; and the drivers of the disparities in the conditions, including racism, gender inequality and poverty. The strategy’s announcement included place-based variation in health but no other structural drivers of the conditions.
These structural drivers have huge implications in the conditions. For instance, in cardiovascular disease, the prevalence of diabetes is between three and five times higher, and type 2 diabetes occurs ten-to-12 years earlier in ethnic minority groups than in the white British population. In mental health, people from ethnic minority groups have worse access to, experiences with, and outcomes from mental health services, than the white British group. In cancers, Asian and black women have worse outcomes in breast cancer than white British women, and black men have worse survival rates than white men in prostate cancer.
The major conditions strategy is an opportunity to create central consensus on ethnicity data to be used in healthcare
Research from the NHS Race and Health Observatory found that ethnic health inequalities are rooted in structural, institutional and interpersonal racism in the health service and wider society. Better data will enable healthcare leaders to understand and address unwarranted variation in access, experience and outcomes across the whole system. Currently, GPs and hospital systems use different ethnic classifications, which has resulted in individual patients being recorded as belonging to multiple different ethnic groups by different parts of the health system. There has been no new central guidance on ethnicity coding issued to the health service since 2001. The major conditions strategy is an opportunity to create central consensus on ethnicity data to be used in healthcare.
There are important differences in the way that the major conditions present and intersect in men and women. The strategy must explicitly consider the differential impact on women and men as a golden thread throughout.
The rising cost of living has impacted population health (both physical and mental) across the country, exacerbating health inequalities. To narrow the gap in healthy life expectancy, the strategy must look beyond the remit of the Department of Health and Social Care, to address the causes of ill health in communities such as fuel poverty and food and housing insecurity.
3. Health in all policies
“How do we connect data to progress this work? A multimorbidity approach needs to be data and intelligence driven, and that data and intelligence needs to connect the health system with other systems across government. For example, for people with mental illness, Department for Work and Pensions data is probably as critical as health data, as is education data for young people in the CAMHS system, and housing data for people with respiratory conditions. This strategy and approach are a big opportunity to connect that data, but this will require some national levers and investment, to open up what ICSs can do.” NHS Foundation Trust Chief Executive.
“The strategy needs to connect multimorbidity with its drivers. Poverty, housing, smoking, loneliness, employment, diet and exercise. How do the solutions connect back to these drivers? The strategy shouldn’t feel overly NHS-focused, as it’s actually a lot more complicated than that.” Local Authority Place Leader, North West.
“How does national policy join up? We have the levelling up missions, and they don’t quite connect with the NHS forward plan. We need some connectivity at the centre.” ICB Place Leader, North West.
The major conditions strategy is taking forward the government’s health mission from the levelling up white paper (Mission 7: narrow the gap in healthy life expectancy by 2030 and increase healthy life expectancy by 2035). The strategy, therefore, is inherently cross-governmental in its inception. Embedding this cross-government approach in the implementation and delivery of the strategy would be a key lever for success in this mission. Many of our members have said it is an essential component.
Reducing prevalence and improving outcomes of the major conditions requires cross-government activity to harness the health benefits of the social and economic environment. Up to 80 per cent of what affects our physical and mental health comes from outside of the health system: housing; finances; education; air quality; and transport. To fully deliver on its aims, the strategy must outline the government’s plan to adopt a cross-government health in all policies approach.
The strategy should therefore mandate health equity impact assessments of all new government policies
For example, to have the desired impact it will be crucial that the strategy on chronic respiratory diseases is linked not only with the DHSC’s recently announced lung cancer screening programme, but also with the Department for Energy Security and Net Zero’s work on reducing fuel poverty, and the Department for Levelling Up, Housing and Communities’ work on housing standards.
The strategy should therefore mandate health equity impact assessments of all new government policies. It should recommend the creation of a cross-government health committee that assesses the mental and physical health impacts of government policy and programmes, connecting the symptoms of multimorbidity with their causes and ensuring cohesion between national policy that affects health.
4. Take a life-course approach
“In the world of children and young people, prevention is straightforward. If we can get in early, and build services around children and young people, that is the best way to prevent any issues down the line. And these services need to go to where the children are; bringing in partners in education, and empowering and upskilling parents and carers, as key trusted adults around the child, so we can seek to address issues before they become entrenched.” Chief Executive, Voluntary Sector.
“Lots of systems do this, but we break down our transformation work into the lifecycle rather than diseases or conditions: live well, be well, age well, die well. This helps us focus on what matters to the person and focus on the patient, rather than a disease-focused perspective.” ICB Medical Director, South East.
While multimorbidity is more common in adults than in children, adopting a life-course approach so people are born well, live well and age well is essential for reducing the prevalence of the major conditions. Research suggests a link between the increased prevalence in childhood of risk factors for multimorbidity such as obesity and poverty, and younger onset of multimorbidity. Preventing the onset of disease in young people is critical, both for the patient and for the cost to the system.
This is especially true for mental health conditions, of which 75 per cent present before the age of 24. Facilitating access to early intervention support for children and young people’s mental health will be critical to reducing the prevalence of mental ill health in the population. As many as one in six children between the ages of seven and 16 have a probable mental health disorder, and this number increases to one in four young people aged between 17 and 19. Mental health support teams (MHSTs) in schools and colleges address the needs of children and young people by bringing timely access to appropriate care to where the young people are. However, the government is currently only committed to providing these services in just over one in four schools. To embed a preventative, life-course approach, and reduce regional inequality, healthcare leaders are calling for a commitment from government to fund MHSTs in all schools.
Taking a life-course approach means ensuring working-age adults live and age healthily as well
Taking a life-course approach means ensuring working-age adults live and age healthily as well. The major conditions strategy is taking forward the Levelling Up health mission to increase healthy life expectancy by five years by 2035. This will only be possible if we address increased rates of multimorbidity in working age adults over the next decade, as the population ages. Projections found that by 2035, multimorbidity rates will have risen to two thirds of adults over 65, three quarters of adults aged 75-to-84, and nine in ten adults over 85.
Given the challenge that increased rates of multimorbidity presents to the health system, addressing these risk factors across the life course will be key to achieving the strategy’s aim of alleviating pressure on the health service.
Make the most of existing infrastructure and policy
5. The role of integrated care systems
“We have been using community asset-based models to co-create work with our population that is genuinely personalised. This includes approaches to tackling food, fuel and housing poverty, and ICSs as a system are in a really good place to deliver across partners on some of this, and it’s about trying to utilise that ability.” ICB Clinical Lead, London.
Integration is crucial to create a health system that recognises and treats multimorbidity, so the multiple conditions strategy must build on the infrastructure that has already been established and is working here.
Integrated care systems are key local partners to deliver on the aims of the major conditions strategy, given their focus on improving population health outcomes, reducing health inequalities, enhancing productivity and supporting social and economic development. Many systems are already overlaying data from different system partners to identify and treat at-risk patients. The strategy must make the most of the opportunity presented by integrated care systems, rather than adding more layers of complexity to the existing service.
The strategy must make the most of the opportunity presented by integrated care systems, rather than adding more layers of complexity to the existing service
System leaders use mechanisms such as pooling budgets across systems to improve population health and wellbeing with partners locally. The recent Hewitt review highlighted that the current mechanism for formal pooled budget arrangements under section 75 of the NHS Act 2006 are ‘unnecessarily bureaucratic and narrow, and do not allow for effective transparency.’ It recommended that the review of section 75 legislation is accelerated, with a view to include the full range of primary care services; social care providers; voluntary, community and social enterprise providers; and housing providers to reflect the full healthcare ecosystem in budget-pooling arrangements.
6. The role of primary care networks
“We do have a good system of managing multimorbidity, it’s called primary care. We shouldn’t forget that this needs investment and support.” Director of Public Health, North East and Yorkshire.
Primary care is where the vast majority of major conditions are detected and where patients with these conditions receive most of their care. For example, primary care networks (PCNs) provide mental health practitioners through the Additional Roles Reimbursement Scheme (ARRS), co-funded by PCNs and local mental health trusts. These professionals support people with mental health needs within primary care settings, which is a critical service, given that as many as 30 per cent of people accessing primary care have a mental health component to their illness and about 90 per cent of people with mental health conditions are cared for entirely within primary care. Ensuring that people with mental health conditions are able to access timely care will be essential to the strategy achieving its aim of reducing ill-health-related labour market inactivity. A recent report from the Office for Budget Responsibility found that the largest increase in economic inactivity has been among people experiencing mental health problems and other unspecified conditions.
Stability for primary care practitioners will be essential to the strategy’s successful delivery
With the incidence of multimorbidity rising, primary care is managing patients with increasingly complex needs while simultaneously facing significant capacity constraints. Stability for primary care practitioners will be essential to the strategy’s successful delivery. This will require formal commitment to PCNs beyond 2024, when the current five-year framework for the GP contract comes to an end.
PCNs introduced a range of services into primary care, which are related to prevention and/or early diagnosis of major conditions, including early cancer diagnosis; cardiovascular disease prevention and diagnosis; tackling neighbourhood health inequalities; enhanced health in care homes; social prescribing and personalised care, as well as anticipatory care (with system-level anticipatory care plans).
These services have proven successful. For instance, the NHS is catching cancers at stages one or two at the highest proportion on record, making progress towards the 75 per cent target from the NHS Long Term Plan. However, the 23/24 PCN Direct Enhanced Service (DES) contract moved the performance-based funding that was linked to these services into the Capacity and Access funds that are based around achieving access targets, such as same-day assessment and two-week targets. This disincentivises provision with the assumption that these services are now business as usual. In practice, there has been no additional funding for the access targets, even though there is still progress to be made, such as on achieving the NHS Long Term Plan targets on early cancer diagnosis. Instead, funding has moved away from prevention and early diagnosis services.
Therefore, a commitment to PCNs through continued funding beyond 2024 must be included in the strategy. Funding for key preventative services provided by PCNs must also be reinstated.
7. Build on existing policy in this space
“Let’s not have parallel things railing forward. We have CORE20PLUS5 already, which we are using really effectively. Let’s stick with that as a methodology and develop that further.” ICB Medical Director, South East.
“We were surprised not to see CORE20+5 as part of the call for evidence on the strategy. We don’t need the next big thing from the centre, it needs to form part of what has already been done, around prevention, health inequalities, CORE20PLUS5.” ICB Medical Director, North East and Yorkshire.
The strategy must build on existing policies and frameworks that are working well, such as personalisation through population health management solutions, as set out in the NHS Long Term Plan, and NHS England’s Core20PLUS5 approach to reducing healthcare inequalities. The Core20PLUS5 approach, through community connectors, ambassadors and accelerator sites, develops local health inequalities improvement knowledge and skills, as well as connecting those with influence in the community to help engage local people with local services.
Population health management allows primary care to identify and address major conditions within their local populations. For example, in mental health, Healthier South Wirral PCN identified the need for a substance misuse service for children and young people after analysing its population health data, and was then able to set up a partnership with the voluntary sector to provide this service. Many other PCNs are seeking to use this approach but find that support for population health management is lacking, in both the skills and tools to implement it. Primary care networks need specific funding to be made available for population health management for training, access to requisite data sets, and analytics tools.
Implementation
8. Outcomes-focused
“One of the advantages of ICBs and ICPs is that you can give people a bit more flexibility to be able to adjust things to deliver according to the population that local leaders know and understand. What we want to see come through in the strategy is that it’s more about outcomes, than telling people how to do things to the nth degree.” ICB Deputy Chief Executive, North West.
“The more this goes into the ‘how,’ and ‘preferred models,’ the more this is disruptive. Everybody will have a range of approaches that have been developed over time. Instead, the strategy should answer: what do you want us to achieve? What does success look like? What are the outcomes we should be measuring? This is what must be in the strategy – flexibility without a defined way to do it. This way, citizens can be involved in shaping what they want from the service and it will make the most of local opportunities.” ICB Chair, South West.
The recent Hewitt review set out a number of recommendations around the autonomy and accountability of integrated care systems. Recommendations 11 and 22 called for fewer national targets to allow greater opportunities for priority setting locally. In keeping with the seventh ask in this paper, for the major conditions strategy to build on existing policy in this space, health and care leaders are calling for this strategy to target outcomes, rather than how these outcomes are achieved. Local health and care leaders know their communities best and must be granted the flexibility to deliver services accordingly. Rather than a strategy that dictates process and procedure, the focus must stay on healthcare outcomes.
9. Move to a workforce working in a more integrated way
“A cultural change will be needed. It’s critical that patients can see the right specialists in the right place and time, but from a multimorbidity perspective, lots of individuals live with two or more of these conditions and yet their care and treatment might be siloed. Where do we have the opportunity to change the way we work across health and care to give a better experience to people when they are on these pathways?” ICB Chief Executive, North East and Yorkshire.
The recently published NHS Long Term Workforce Plan acknowledged that ‘multimorbidity challenges the specialised approach to medicine… As we move forward, we will increasingly need medical and other clinical professionals with generalist and core skills to manage and support patients with seemingly unrelated diseases.’
NHS Employers, in partnership with the LGA, ADASS and Skills for Care, published an infographic to highlight the challenges that individuals face when managing multiple health conditions, showing how integrated workforce thinking can benefit a person’s life, as well as provide opportunities to upskill the workforce. Integrated Workforce Thinking Across Systems offers practical solutions to support ICSs to adopt integrated workforce thinking, which can reduce the treatment burden experienced by patients experiencing multimorbidity and improve their quality of life.
Workforce planning needs to be coordinated nationally across health and social care, to ensure the workforce is sustainable for the future
The guide also outlines that there are actions needed from the centre to support the integrated workforce transition. Workforce planning needs to be coordinated nationally across health and social care, to ensure the workforce is sustainable for the future. The guide highlights the need for a more integrated and strategic approach to workforce planning across health and social care, and flags that decisions taken to address recruitment and retention in one part of the sector may have implications in the other.
“A decision to address recruitment and retention issues in one sector may have implications in the other, or fail to take advantage of opportunities arising from joint working. Most recruitment takes place from the same pool of ASC staff and so the pay differentials between health and social care staff results in a one-way flow of staff joining health organisations due to better pay and conditions. It is important to highlight that the average care worker pay is £1 per hour less than healthcare assistants in the NHS that are new to their roles. Challenges are not only around pay and conditions but include career progression, training and qualifications.” Integrated Workforce Thinking Across Systems, NHS Employers.
The recent NHS Long Term Workforce Plan was welcomed by NHS leaders, but an integrated workforce will be required to address the major conditions in an ageing population. This is why it needs to be accompanied by a long-term workforce plan for social care: something that the NHS Confederation has recently written to the Prime Minister to request.
Moving to a more integrated workforce will also require policymaking that considers the full breadth of Agenda for Change (AfC) staff, including those not employed by statutory NHS bodies, but who are on AfC pay rates, such as primary care staff and those employed by community interest companies. The recent AfC pay settlement did not account for these staff, who provide care in the community and closer to home. This is creating a widening gap within the health and care workforce. To move towards a truly integrated workforce, where care is not provided in siloes, there needs to be parity of esteem here.
Summary and next steps
The major conditions strategy is a welcome opportunity to reframe how we address illness in England. Patients increasingly present with two or more conditions, so taking a multimorbidity approach across the health system will benefit patients and facilitate more efficient use of clinical time.
This paper has outlined recommendations and policy levers that healthcare leaders are calling for the strategy to include, in order to deliver on its aims to narrow the healthy life expectancy gap, reduce ill-health related labour market inactivity, and alleviate pressure on the health service.
These leaders called for the strategy to create a healthy society; make the most of existing infrastructure and policy; and consider the sector’s views on implementation.
The government is expected to publish the strategy’s interim report shortly and we are looking forward to assessing the extent to which the report aligns with the recommendations of healthcare leaders. Following the interim report’s publication, the NHS Confederation plans to hold further engagement with members and the major conditions strategy team, to support the inclusion of insights from the sector within the final strategy, due this winter.
