The use of outreach nurses to support patients living with multimorbidities is a key pillar of a planned Long Term Conditions Framework for Scotland, now under consultation.
The plan proposes moving away from a condition-specific focus, instead bringing together all long term conditions under a ‘single policy umbrella’ to improve early identification and care for patients.
The framework will work to highlight improvements that can be made to the treatment of all long-term conditions, as well as targeted approaches to specific conditions, the Scottish government has said.
This could also include the roll-out of a self-management workbook across all long term conditions, and an awareness and prevention programme to identify condition risk factors.
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Actions from existing strategies and frameworks which are yet to be delivered will now be considered as part of the new framework and action plan, the Scottish government has confirmed.
It is anticipated that improvements around rare diseases, cancer, mental health conditions and congenital conditions will continue to be considered separately.
Details on where the outreach nurse workforce would come from are yet to be made clear.
What does the consultation include?
The consultation asks for feedback on what is already working effectively in long term conditions care, and what improvements could be made.
Jenni Minto, Scotland’s public health and women’s health minister, said the framework will examine how to improve the approach to healthcare quality, care, support and inequalities.
‘We want to empower NHS boards and other partner organisations to deliver improvements that benefit as many people as possible, including those living with multiple conditions,’ she said.
She added that the plan hopes to treat patients ‘as individuals’, rather than seeing them ‘segmented by [their] condition’.
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‘It is for these reasons that we are reviewing our approach to policy for the care and support of people with long term conditions,’ Ms Minto explained.
The consultation launch coincides with some ongoing condition-specific strategies.
This includes a respiratory care action plan, first launched in 2021 and due to conclude in 2026. Chest Heart & Stroke Scotland (CHSS) has called on the Scottish government to fund and implement the plan, particularly to address the care needs of people with COPD, following ‘minimal progress’ on the proposal.
In the consultation document the Scottish government accepted that long-term conditions have, in the past, not been ‘allocated as impactfully’ as they could have been.
Responses from individuals or organisations are invited until 20 July. Scotland is expected to publish the final Long Term Conditions Framework later this year.
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