Long term conditions and frailty

We believe that we can look after most people with long term conditions in their homes – where they would prefer to be – by making sure their care is properly planned and regularly assessed.

Every patient with a long term condition, such as diabetes or lung disease, or who is frail, should have care plan to help them stay well. This should start at the time of diagnosis. The care plan should be a partnership between the patient and a named health care professional – likely to be their doctor or nurse. Patients need the plan to help them to know what is ‘normal’ for their condition, what isn’t and who to call if they need help.

When people know what to expect they have better control over their health and will understand when they need urgent medical care. This means that many problems currently treated at A&E could be dealt with in the community or through a walk in service, allowing the patient to return home the same day.