With mortality from many conditions decreasing, more people are living with multiple long-term conditions. The National Institute for Health and Care Excellence (NICE) clinical guidelines set standards to help ensure that patients receive high-quality care. However, for people with more than one condition, this can result in a significant burden of treatment, and the patient’s individual goals and circumstances need to be considered.
During this unprecedented time for the health service, QualityWatch will continue to monitor the quality of health and social care as best it can. For this update, we used trend data from national clinical audits to look at changes in the quality of care for patients with heart attack, stroke, diabetes and COPD. We also examined wider support for people with long-term conditions, such as in employment and housing. The latest data presented here is from 2018 and early 2019, before the Covid-19 outbreak took place.
While some measures, such as diabetes care and the rate of employment for adults with a long-term condition, show an improvement, other measures, such as how supported patients feel to manage their condition, have not improved. A summary of our long-term conditions indicators is shown below. Click on the links for more detailed content and analysis.
Care for heart attack patients
Patients with ST-elevation myocardial infarction (STEMI) should receive primary percutaneous coronary intervention (PCI) within 90 minutes of arriving at hospital.
- Between 2004/05 and 2013/14, there was a significant increase in the proportion of STEMI patients receiving primary PCI within 90 minutes of arrival at a heart attack centre, from 52% to 92%. Since then, there has been a slight decrease to 88% in 2017/18.
Patients with non-ST elevation myocardial infarction (nSTEMI) should undergo coronary angiography within 72 hours of admission.
- Delays from admission to angiography for nSTEMI patients have not improved over time. In 2010/11, 55% of patients with nSTEMI underwent angiography within 72 hours, and this increased only slightly to 57% in 2017/18. This demonstrates an area for significant quality improvement.
All eligible patients should be offered cardiac rehabilitation after a cardiac event.
- The percentage of eligible patients accessing cardiac rehabilitation in England increased from 44% in 2006-07 to 50% in 2017-18. In the Long Term Plan, NHS England introduced a goal to increase uptake to 85% by 2028. To meet this target, uptake will have to increase considerably. In 2017-18, uptake was highest in Wales (61%) and lowest in Northern Ireland (49%).
Stroke care
People presenting with acute stroke should have a brain scan within 1 hour and be admitted to a stroke unit within 4 hours of arrival at hospital.
- Between 2013/14 and 2018/19, the percentage of patients who had a brain scan within 1 hour of arrival at hospital increased from 42% to 55%.
- Over the last six years, the percentage of patients admitted to a stroke unit within 4 hours fluctuated between 57% and 58%. It is not clear why no improvement has been made, but there are suggestions that it could be due to increasing problems with bed availability.
Stroke patients should be assessed by a nurse within 24 hours AND at least one therapist within 24 hours AND all relevant therapists within 72 hours AND have rehab goals agreed within 5 days.
- Between 2013/14 and 2018/19, the proportion of patients receiving a timely multidisciplinary review increased from 44% to 64%. The percentage increase may reflect greater weekend working among therapy staff.
Patients having stroke rehabilitation in hospital or in the community should be offered at least 45 minutes of each relevant therapy for a minimum of five days a week.
- In 2018/19, compliance against the speech and language therapy target was 52% compared with 82% for physiotherapy and 91% for occupational therapy.
All applicable patients should receive a joint health and social care plan on discharge.
- The percentage of stroke patients receiving a joint health and social care plan on discharge has increased over time, from 70% in 2013/14 to 94% in 2018/19.
Diabetes care
NICE recommends that all people with diabetes should receive nine annual care processes.
- Fewer people with Type 1 than with Type 2 diabetes receive their annual checks in England.
- Urine albumin and foot surveillance are most often missed out, while blood pressure and smoking history are most often checked.
NICE recommends treatment targets for HbA1c (glucose control), blood pressure and serum cholesterol.
- Glucose control targets are achieved in Type 1 diabetes less than half as often as in Type 2 diabetes.
- Over the last six years the proportion of patients achieving all three treatment targets in England has improved for both Type 1 and Type 2 diabetes, by 3.7 and 4.2 percentage points respectively.
Children and young people with diabetes should receive seven annual care processes.
- Between 2004/05 and 2018/19, the percentage of children and young people with Type 1 diabetes receiving all seven care processes increased from 2% to 55%.
Care for COPD patients
Patients with COPD exacerbations should be reviewed by a member of the respiratory team within 24 hours.
- There was an increase in the proportion of COPD admissions reviewed within 24 hours, from 49% in 2014 to 64% between September 2017 and September 2018.
Admitted patients with COPD should have key clinical information recorded.
- Between September 2017 and September 2018, 72% of admissions requiring oxygen were prescribed it.
- A spirometry result was available for only 41% of admissions between September 2017 and September 2018, compared to 46% in 2014.
- Between September 2017 and September 2018, of the admitted COPD patients who were current smokers, only 26% were prescribed smoking cessation pharmacotherapy during their admission.
Approximately 20% of patients are acidotic on arrival and should receive non-invasive ventilation (NIV).
- Only 10% of patients received NIV treatment between September 2017 and September 2018 compared to 12% in 2014. Of those who received it, only 21% received NIV within two hours of arrival.
Admitted COPD patients should receive a British Thoracic Society, or equivalent, discharge bundle.
- Between September 2017 and September 2018, only 67% of admitted patients received a discharge bundle, and 16% had ‘no follow-up arrangements apparent’ given as a response.
Cancer survival rates
- The cancers with the lowest five-year survival estimates are mesothelioma (7%), pancreatic cancer (7%) and brain cancer (12%). Testicular cancer (95%), melanoma of skin (91%) and thyroid cancer (87%) have the highest five-year survival estimates.
Emergency admissions for children with chronic conditions
Asthma
- Between 2008/09 and 2018/19, the rate of emergency admissions for asthma in children and young people aged 5 to 19 remained relatively constant. But the rate in children aged 0 to 4 years decreased considerably. This could largely be due to a reduction in over-diagnosis of asthma in young children by clinicians.
- In 2018/19, the rate of emergency admissions for asthma in children aged 5 to 9 was over 1.5 times as high as the rate in children aged 10 to 14, and nearly 2.5 times as high as the rate in young people aged 15 to 24.
Diabetes
- The rates of emergency admissions for Type 1 diabetes have decreased for children aged 0 to 14 and remained stable for those aged 15 to 19.
- There has been a striking increase in emergency admissions for diabetes in young people aged 20 to 24. The worsening trend is likely to be explained by fragmented and variable service quality, as young people with diabetes transition to adult services.
Epilepsy
- Overall, emergency admissions for epilepsy have remained relatively constant over time for children and young people. Children aged 0 to 4 have the highest emergency admission rate for epilepsy, at 94 per 100,000 population in 2018/19.
Supporting patients to manage their long-term condition(s)
- Between 2012 and 2017, the proportion of patients who ‘definitely’ had enough support from local services or organisations to help them manage their long-term health condition(s) decreased from 54% to 51%. In 2019, only 42% of patients ‘definitely’ had enough support in the last 12 months, and 37% had not received enough. Note that results from the 2018 and 2019 GP Patient Surveys are not directly comparable with previous surveys.
- Only 30% of patients aged 16 to 24 ‘definitely’ felt supported to manage their long-term condition in 2019, compared to 53% of patients aged 65 to 74.
- In 2019, a smaller proportion of people from the most deprived areas (52%) felt supported to manage their long-term condition compared to people from the least deprived areas (63%).
Supporting people in employment
- The proportion of adults with a learning disability in paid employment is very low and has fluctuated over time, from a high of 7.1% in 2011-12 to a low of 5.7% in 2016-17.
- The employment rate among adults with a long-term condition increased from 58% in Q1 2007/08 to 66% in Q2 2019/20.
Adults with learning disabilities who live in their own home or with their family
- The proportion of adults aged 18-64 with a learning disability who live in their own home or with their family increased from 74% in 2014-15 to 77% in 2018-19.