Success and failure in integrated models of nursing for long term conditions: Multiple case studies of whole systems

Background: Current projections indicate that the UK faces a 252% increase in people aged

over 65 with one or more long term conditions (LTC) by 2050. Nurses, managing their own

caseloads and clinics, working across sectors and organisational boundaries and as part of

a wider multi-disciplinary team, are frequently seen as key to managing this growing

demand. However, the evidence base informing the nursing role in managing LTC, the

most effective con?guration of the multi-disciplinary team and the policy evidence

relating to the infrastructure required to support cross organisational working, remains

weak.

Objectives: To explore, identify and characterise the origins, processes and outcomes of

effective chronic disease management models and the nursing contributions to such

models.

Design: Case study whole systems analysis using qualitative interview methods.

Settings: Two community matron services, two primary care (GP) practice nursing

services, two hospital based specialist nursing services were purposefully sampled from

across England and Wales.

Participants: Selection criteria were derived using a consensus conference. The nurses in

the service, all patients and carers on the caseload, members of the multi-disciplinary

team and stakeholders were invited to participate.

Methods: Semi-structured interviews with all participants, thematic analysis within a

whole system framework.

Results: The study found high levels of clinical nursing expertise which in the case of the

community matrons was meeting the aim of reducing hospital admissions. Both the

primary care and hospital nurse specialist indicate similar levels of clinical expertise

which was highly valued by medical colleagues and patients. Patients continued to

experience fragmented care determined by diagnostic categories rather than patient need

and by the speci?c remit of the clinic or service the patient was using. Patient data systems

are still organised around the impact on services and prevalence of disease at an individual

level and not around the patient experience of disease.

Conclusion: Nurses are making a major contribution to meeting the policy objectives for long

term conditions. Primary care nurses and hospital nurse specialists do broadly similar roles.

The scope of the nursing roles and services studied were idiosyncratic, opportunistic and

reactive, rather than planned and commissioned on an analysis of local population need.