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The nursing contribution to chronic disease management: a whole systems approach: Report for the National Institute for Health Research Service Delivery and Organisation programme

Kendall, Sally, Wilson, Patricia M., Procter, Susan, Brooks, Fiona, Bunn, Frances, Gage, Heather, McNeilly, Elaine (2010) The nursing contribution to chronic disease management: a whole systems approach: Report for the National Institute for Health Research Service Delivery and Organisation programme. HMSO, London, 364 pp. (KAR id:47922)

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experienced by service users and carers.

To explore, identify and characterise the origins, processes and outcomes of effective CDM models and the nursing contribution to such models using a whole systems approach

The study was divided into three phases:

Phase 2: A consensus conference of nurses working within CDM. Sampling criteria were derived from the conference and selected nurses attended a follow up workshop where case study sites were identified.

Sample: 7 case studies representing 4 CDM models. These were: i) public health nursing model; ii) primary care nursing model; iii) condition specific nurse specialist model; iv) community matron model.

• semi-structured interviews with practitioners, patients, their carers, managers and commissioners

• psycho-social and clinical outcome data from specific conditions

Benchmarking outcomes: Adults benchmarked against the Health Outcomes Data Repository (HODaR) dataset (Currie et al, 2005). Young people were benchmarked against the Health Behaviour of School aged Children Survey (Currie et al, 2008).

Analysis: A whole system methodology was used to establish the principles of CDM. i) The causal system is a “network of causal relationships” and focuses on long term trends and processes. ii) The data system recognises that for many important areas there is very little data. Where a particular explanatory factor is important but precise data are lacking, a range of methods should be

Key findings

Public Health Model

• The lead school nurse has provided a vision for asthma management in school-aged children. This has led to the implementation of the school asthma strategy, and the ensuing impacts including growing awareness, prevention of hospital admissions, confidence in schools about asthma management and healthier children.

• GP practices are providing planned and routine management of chronic disease, tending to focus on single diseases treated in isolation. Care is geared to the needs of the uncomplicated stable patient.

• Patients with multiple diagnoses continue to experience difficulty in accessing services or practice that is designed to provide a coherent response to the idiosyncratic range of diseases with which they present.

• While the QOF system has clearly been instrumental in developing and sustaining a primary care nursing model of CDM, it has also limited the scope of the model to single diseases recordable on a register, rather than focus on patient centred care needs.

• The model works under a disease focused system underpinned by evidence based medicine exemplified by NICE guidelines and NSF’s.

• A focus on self-management in LTCs gives particular impetus to nurse-led enablement of self-management.

Community Matron Model

• The model has been championed by the community matrons themselves, and the pressure to deliver observable results such as hospital admission reductions has been significant.

Survey Findings

our study within the last six weeks. The differences between the HODaR and case study patients in service use cannot easily be explained but it could be speculated when referring to the qualitative data that the case study patients are benefiting from nurse-led care.

The nurse costs per patient are at least ten times higher for community matrons conducting CDM than for nurses working in other CDM models. The pattern of service utilisation is consistent with the focus of the community matron role to provide intensive input to vulnerable patients.

Nurses are spearheading the kind of approaches at the heart of current health policies (Department of Health, 2008a). However, tensions in health policy and inherent contradictions in the context of health care delivery are hampering the implementation of CDM models and limiting the contribution nurses are able to make to CDM. These include:

? QOF reinforced a disease centric approach

? the value of the public health model may not be captured in evaluation tools which focus on the individual patient experience.

Commissioners and providers

2. Promote the role of the nurses in LTC management to patients and the wider community.

4. Improve the support and supervision for nurses working within new roles.

6. Develop organisations that are enabling of innovation and actively seek funding for initiatives that provide an environment where nurses can reach their potential in improving LTC services.



2. Work to develop appropriate measures of nursing outcomes in LTC management including not only bureaucratic and physiological outcomes, but patient-identified outcomes.

1. Investment should be made into changing patient perceptions about the traditional division of labour, the nurses’ role and skills, and the expertise available in primary care for CDM.

3. Long-term funding of prospective evaluations to enable identification of CDM outcomes.

5. Development of appropriate measures of patient experience that can be used as part of the quality outcome measures.

7. The importance of whole system working needs to be identified in the planning of services.

8. Research into the role of the health visitor in chronic disease management within a public health model.

Item Type: Research report (external)
Additional information: SDO Project (08/1605/121)
Subjects: R Medicine > RA Public aspects of medicine
R Medicine > RT Nursing
Divisions: Divisions > Division for the Study of Law, Society and Social Justice > School of Social Policy, Sociology and Social Research > Centre for Health Services Studies
Depositing User: Tony Rees
Date Deposited: 09 Apr 2015 14:16 UTC
Last Modified: 16 Feb 2021 13:24 UTC
Resource URI: (The current URI for this page, for reference purposes)
Wilson, Patricia M.:
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