Putting function first: redesigning the primary care management of long-term conditions

Abstract

Long-term conditions comprise the biggest burden on the NHS, involving more than half of all GP consultations, 65% of outpatient visits, and 70% of inpatient bed days. 1 Their prevalence rises with age, affecting 50% of people by the age of 50 years and 80% by the age of 65 years. As older people accumulate more long-term conditions, they become increasingly frail and are at higher risk of falls, disability, admission to hospital, and the need for long-term care. In order to address this burden, a revolution is needed in their primary care management. Physical capability, or 'physical functioning', describes an individual's capacity to undertake physical tasks of everyday living. Care and support are needed when a person is no longer able to manage tasks such as washing, dressing, and feeding. Indeed, failure to get to the toilet on time is a frequent reason for admission to residential care. 2 Maintaining physical function is one of the most important factors for quality of life among older adults and a central goal for all people with long-term conditions. Physical inactivity is one of the strongest predictors of physical disability in older people, and physically active people have better levels of physical and psychosocial functioning. Although normal ageing leads to a decline in physical fitness, this decline is much worse if a person has a sedentary occupation or lifestyle. However, the detrimental effects of prolonged sitting on mortality can be ameliorated by 60-75 minutes of moderateintensity physical activity per day, such as brisk walking. 3 This is much more than the minimum physical activity recommendation of 30 minutes' moderate-intensity physical activity on 5 days per week, which over half of the UK adult population do not meet. Indeed, a quarter are classified as 'inactive', participating in less than 30 minutes' physical activity per week. There is an inverse association of physical activity with age and with multimorbidity. So, the drastic decline in physical functioning that many older people experience is not an inevitable part of ageing. The National Institute for Health and Care Excellence (NICE) has issued guidelines for the prevention of frailty, disability, and dementia in mid-life 4 and recommend that

Re-braiding the Strands of Life through Community Rehabilitation, Home Care, and Informal Support: A Longitudinal Collective Case Study

“…Our study findings seem to suggest that maintaining physical function was a key aspect for the participants, although not all services provided this aspect for the long term. Functioning has been referred to as a third health indicator in addition to mortality and morbidity (Cieza, 2019; Stucki & Bickenbach, 2017), and as the sixth vital sign (Richardson et al, 2012; Williams & Law, 2018). We suggest that a reframing of rehabilitation services at the health system level is needed to support older adults in maintaining their function.…”

Exploring the delivery of community rehabilitation services for older people in an urban Canadian setting: Perspectives of service providers, managers and health system administrators

“…Maintaining and restoring function are important for quality of life and a key aim for people with long‐term conditions (Williams & Law, 2018). Physical functioning has been referred to as the sixth vital sign (Richardson et al., 2012; Williams & Law, 2018), and identified as a third health indicator, in addition to mortality and morbidity (Cieza, 2019). Therefore, ensuring that maintenance and restoration of function are a primary focus of community rehabilitation services for older people should be a priority.…”

Promoting physical activity and physical function in people with long-term conditions in primary care: the Function First realist synthesis with co-design

“…Therefore, a better way for primary care to help reduce functional decline and promote physical activity is needed. 76 This includes a consideration of changes in the culture of primary care and an understanding that physical activity promotion is an important health promotion activity and long-term condition management, as well as having the tools available to assist the workforce and change behaviour.…”