The Department of Health are currently working on a long-term conditions strategy, and their website is full of links to interesting articles highlighting the issues and their possible solutions at many different levels.
Don Redding (Director of Policy at National Voices) has written an excellent blog post. He makes two very important points.
Firstly, that "Long term conditions are not ‘managed’ by health, social care or other government services, but by the people who live with them. For us and our carers, this is a 24/7 reality." He later goes on to say that this represents challenges at the individual patient level and at a higher service level. This is a key idea, because any new system will have to meet the needs and provide beneficial outcomes for individual patients, but must be scale-able, so that many patients can benefit. There is often conflict between these two!
The second point is very reassuring to see. As a patient I have found keeping track of my different doctors quite difficult and often longed for someone to bring it all together and oversee my meandering journey through the NHS. Don linked to 'care webs', which clearly illustrate the "bewildering complexity of services [patients] need to access", and says that "what people most want is access to a known care co-ordinator who both knows about the patient and their condition and is able to plan and arrange their packages of care." Interestingly, he goes on to say that "this is not always the same as ‘integration’ – for the person at the centre, coordination matters more than whether the services are actually merged or joined together."