Long Term Conditions across the Lifecourse 2015

New Information - 02 November 2015

Evaluation highlights areas for improvement in long term conditions care

Older people living with multiple long term conditions are generally happy with the NHS but often find the health and care system is not set up for their needs.

Source: Ipsos Ethnography Centre of Excellence (ECE)/NHS England


JSNA Report



What is the background to this JSNA?

The Department of Health estimates that around 15 million people in England have one or more long term condition(s) (LTC).[1]  A LTC has been defined as ‘a health problem that can’t be cured but can be controlled by medication or other therapies’.  LTC includes any ongoing, long term or recurring condition requiring constant care that can have a significant impact on people’s lives, limiting in quality of life.  In the GP Survey, nearly a third of people in Cambridgeshire (31.7%) reported having at least one LTC[2] and the 2011 census found that 90,420 people (15.1% of household residents) reported a long term activity-limiting illness in Cambridgeshire.[3]

The Cambridgeshire Health and Wellbeing Board have requested a Joint Strategic Needs Assessment (JSNA) on Long Term Conditions across the Lifecourse.  The JSNA will include work to estimate current and future numbers of people with LTCs in Cambridgeshire given population growth and ageing.   A clear and accurate description of the current needs of people with LTCs will provide a foundation for the development of integrated approaches to enhance the health and wellbeing for people with LTCs while promoting independent and inclusive living.

This JSNA aims to complement the work and findings of the Primary Prevention JSNA which together describe local need and identify opportunities for intervention in response to Long Term Conditions across the lifecourse (Figure 1).

Figure 1: A lifecourse approach


Lifecourse Approach


This JSNA is focussed on the management of care for adults and older people with LTC who may be considered ‘at-risk’ of poor health outcomes (such as admission to hospital or increased need for care).  These individuals may not be currently known to acute health or long term social care services, despite being at higher risk of admissions to such services.  Improvements to the management of their care may offer significantly improved health outcomes for them as individuals, the community that support them, and to those providing services.

Stakeholders and experts involved in the scoping process identified the characteristics that contribute to increasing health needs of principal interest as:

  • Multiple LTCs at the same time.
  • Substantial limitations due to LTCs.
  • People with LTCs experiencing significant pain.
  • Depression and anxiety.

The work will explore evidence-informed approaches to keep people independent, safe and well. Emphasis will be placed on how to ensure care is person-centred and collaborative, recognising that people with LTC are experts in their health.  The vital importance of self-care principles will be highlighted, alongside the opportunities for prevention of ill health across the lifecourse.


There have been several stages in the development of this JSNA.

Due to the scale of the topic of LTCs across the Lifecourse, a thorough scoping process was undertaken.   A stakeholder event was held in November 2014 to understand the views from key stakeholders across health and social care, and explore opportunities to align this JSNA with priority workstreams and local commissioning decisions to ensure the JSNA is responsive to stakeholder needs.  Participants considered local data on mortality, admissions and prevalence; multimorbidity and limiting conditions were explored through group discussions.  Recurring themes were the factors that impinge on the quality of life for individuals, particularly chronic pain, and poor mental health including depression and anxiety.  Stakeholders were interested in care principles that might be extended across a range of disease conditions where there were some commonalities, such as information on approaches where individuals could be supported and empowered to make changes to live well, and where strategic changes could be made at system-level to improve health outcomes, improve quality, and reduce costs.

The scoping paper was approved by the Health and Wellbeing Board in January 2015, detailing a thematic focus on people with adult-onset LTCs at high risk of poor health outcomes.  In light of the agreed scope, a JSNA working group with colleagues from across Cambridgeshire County Council and Cambridgeshire and Peterborough Clinical Commissioning Group (CCG), considered evidence and input including key epidemiological data, high-quality evidence and national guidance, patient and citizen views, complemented by ongoing consultation with stakeholders to produce this work.  A local views workshop was also held in April to ensure the views of people with LTCs and their carers remained at the centre of the JSNA.

Figure 2: Flow chart to describe the Cambridgeshire JSNA process

The preliminary data and evidence was presented to 40 stakeholders at an event in May 2015 to jointly elucidate key findings.  The event concluded with Panel discussion, driven by key Stakeholder Panel members from Cambridgeshire County Council, Cambridgeshire and Peterborough CCG, Uniting Care Partnership and Hunts Forum (representing local third sector organisations) to explore the application and alignment of this work with current local workstreams across agencies.

This JSNA provides important evidence and information to support the commissioning of services across health and social care and to encourage awareness and signposting of available public health improvement programmes and services available across Cambridgeshire.  The process and production of the JSNA is timely as new structures and service design models are currently in effect across the county and for which this piece of work will provide a base and foundation for further work across several local priority areas.



[1] Department of Health LTC compendium 3rd Edition

[2] LTC dashboard NHS England | 2013/14 GP Survey data, response rate 34.3%

[3] Defined as an illness lasting at least 12 months, with any limitation.2011 Census, ONS


Summary Presentation Slides


Report and Data Supplements

The content of the report is complemented by data supplements on key conditions that are prevalent in Cambridgeshire and Peterborough (see below)