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Published: 12/02/2016



What is a Long Term Condition?

The National Health Committee defines a long term condition as any ongoing, long-term or recurring condition that can have a significant impact on people’s lives.  Long term conditions include diabetes, cardiovascular disease (including stroke and heart failure), cancer, asthma, chronic obstructive pulmonary disease, arthritis and musculoskeletal disease, dementia and mental health problems and disorders.  They share the following characteristics:

  • they have complex and multiple causes;

  • they usually have a gradual onset but can have sudden acute stages;

  • they occur across the life-cycle becoming more prevalent with increasing age;

  • they compromise quality of life through physical limitation and disability;

  • they are long term and persistent, leading to a gradual deterioration of health;

  • while not immediately life-threatening, are the most common and leading cause of premature mortality.

In addition it is important to note that many patients (probably around half) have more than one condition.

The rise in the incidence of long term conditions can be attributed to an increase in lifestyle risk factors, the ageing population, and socioeconomic determinants of health. A majority of long term conditions are preventable or could be better managed.

The New Zealand context

All New Zealanders are affected by long-term conditions – whether as carers for family and whanau, taxpayers, health professionals or managing their own long-term condition.  Long-term conditions are much more common than previously realised with more than two in three adults have been diagnosed as having or having had a long-term condition expected to last 6 months or more (A Portrait of Health, Ministry of Health 2008). Long-term conditions are the leading cause of hospitalisations, accounts for most preventable deaths and are estimated to consume a major proportion of our health care funds. They are also a barrier to independence, participation in the workforce and in society. 

Furthermore long term conditions account for a higher proportion of illness and deaths among Maori, people on low incomes and Pacific peoples than among the general population. The need to reduce health inequalities remains urgent.  Work to prevent and manage long-term conditions should ensure outcomes for groups at greatest disadvantage improve earliest and most significantly.

ADHB’s Commitment for Long-Term Conditions in the Primary Health Care Plan

To enable people/whanau to prevent and live well with long-term conditions



To re-orient services to improve the prevention, detection and management of long-term conditions within a life-course approach.


Our Actions:

  1. Implement a Long-Term Conditions Framework that supports self-management, reorients the health care system and harnesses community resources to better prevent and manage long-term conditions (see framework below)

  2. Ensure information systems are supportive of an integrated approach to long-term conditions.
  3. Promote and advocate for models of care that ensure we provide opportunities to involve families/whānau in care of their long-term conditions.
  4. Enhance the ability of primary care to assist older people and people with disabilities to remain in their own homes as long as possible.
  5. Ensure that people who have palliative care needs have access to the appropriate generalist support in the community.
  6. Encourage the development of comprehensive screening, treatment and review practices that include workplace locations.
  7. Work in collaboration with key stakeholders to review the role of district nursing and increase district nursing involvement in the management of people with long term conditions and palliative care, in line with the recommendations of the recent palliative care review.
  8. Acknowledge that people with Long Term conditions often have mental health needs and ensure that primary mental health services are available for these people.


From the Primary Health Care Plan for Auckland City 2008-2020

August 2008

Auckland DHB Framework for Long-Term Conditions

Our work plan covers the four work-streams identified in the framework; strengthening community participation and action, self/whanau resilience, empowering primary care and reorienting specialist support (including integrating with primary care).  Work in these areas includes:

 1         Strengthening community participation and action

·         Taking a health promotion approach - see Nutrition & Physical Activity

·         Information about how to stay healthy

·         Reducing inequalities


 2         Self/whanau resilience

·         Developing health literacy

·         Providing self management education and support (for example Diabetes Self Management Education and Generic Self Management provided as part of the Healthy Village Action Zone programme – see Pacific Health

·         Providing smoking cessation support

·         Lifestyle change support through primary care


 3         Empowering primary care

·         Providing early intervention programmes – screening and risk identification

·         Delivering evidenced-based care

·         Continuing workforce development

·         Supporting primary care through quality improvement initiatives

·         Supporting primary care with IT tools to better identify and manage their patients with long-term conditions

·         Better integrating primary and secondary care, including improved referral processes

·         Increased access to diagnostics and specialist support


 4         Reorienting specialist support (including integrating with primary care).

·         Developing a neighbourhood or locality approach to healthcare service delivery

·         Basing nurse specialists in community clinics

·         Improving discharge planning

·         Enhanced allied health support links

·         Integrated care

·         Developing clinical pathways

·         Better rehabilitation and palliative care


ADHB Primary Care Collaborative

In 2009-2010, Auckland DHB, the 6 local PHOs at the time and 15 practices combined to focus on optimising the prevention and management of long-term conditions within the community and primary care. Based on an evidence-based and popular quality improvement approach known as the Breakthrough Series Methodology (from the Institute of Healthcare Improvement), this was one of 4 partially funded Ministry of Health pilots of this approach in NZ.

Key components included:

1.   Identification and focus on 3 key topic areas of system redesign, cardiovascular disease/diabetes and self-management support.

2    Introduction of proven change concepts and principles

3    Use of PDSA (Plan, Do, Study, Act) cycles to plan and implement small, doable changes. When done regularly and frequently, such cycles can lead to significant incremental and sustainable improvements.

4    Range of Learning Workshops, facilitator support, website and newsletters to facilitate the sharing of practical solutions and knowledge across practices.

5    The promotion of population health approaches (such as consistent coding, development of disease registers and use of population audit tools) to help identify if changes have resulted in improvements.


This approach has been widely used in Australia, Canada, UK and the USA with impressive results in a wide range of settings – community, hospital teams and more.

For more information visit the collaborative website at

Following the success of this approach, a modified version is currently being implemented focusing on Refugee Health.

Visit the Refugee Health Collaborative website at