About long term conditions

One in four New Zealanders lives with multiple chronic health conditions (also referred to as long-term conditions) that are often experienced by several generations in the same whānau, such as diabetes, heart disease and stroke. The greatest burden of chronic conditions is experienced by Māori and Pacific people, who develop these conditions 10-20 years earlier than non-Māori and non-Pacific.

Given that chronic health conditions are responsible for the majority of ill-health in Aotearoa, concentrating on approaches that improve outcomes for a few important conditions is going to be key to making meaningful change over the next two years and beyond. The selected conditions with the greatest prevalence and inequities are diabetes, cardiovascular diseases, respiratory conditions, stroke, and gout.

Find out more about chronic health conditions in Te Pae Tata (40-41)

The national-level Long Term Conditions work programmes focus on improving equitable health outcomes across the care continuum for people living with, or at risk of, diabetes, cardiovascular diseases (CVD), stroke, and gout.

This mahi considers the common risk factors (including physical inactivity, unhealthy diet, alcohol use, smoking, high blood pressure, and high blood sugar) for these conditions. An increasing focus of our work programmes involves looking at ways to influence, support, and enable early risk identification and management in community and primary care.

These efforts will help to prevent the conditions occurring and to reduce the progression of complications for those living with these conditions. Our national work will also continue to maintain oversight and connection with other aspects of the health system that focus on acute health events and rehabilitation and recovery.

A national-level palliative care programme is also underway. Palliative care is a holistic approach to care that supports those affected by life-limiting conditions to live as well as possible for as long as possible. This includes providing effective pain and symptom management, as well as psychological, social, emotional, and spiritual care.

The current focus of our national palliative care work is to meet the following goal identified for palliative care in Te Pae Tata:

• Develop a nationally-consistent model for paediatric and adult palliative and end-of-life care that is integrated across primary and community health and strengthens the equitable provision of palliative care across Aotearoa.

Our role at a national level is to engage, influence and support how we respond to the following actions relating to Māuiuitanga taumaha | people living with chronic health conditions in Te Pae Tata.   

• Implement accessible and nationally consistent clinical pathways for diabetes, cardiovascular diseases, respiratory conditions, stroke, and gout, supporting specialist teams to integrate with primary and community care providers to create seamless pathways for whānau.
• Identify and support Māori and Pacific NGOs to work with whānau with chronic conditions to support self-management of their conditions.
• Establish a national strategic network in the priority area of Māuiuitanga taumaha | people living with chronic health conditions.

In response to these actions, national-level mahi underway will:

• support people to live healthy lives and reduce the burden and prevalence of chronic health conditions
• focus on prevention, early intervention and self-management of diabetes, CVD, stroke, and gout
• provide national guidance and oversight, informed by consumer, whānau and clinical voice and community needs
• embed holistic, whole-of-whānau, strengths-based support across the chronic health condition disease continuum (from prevention to palliative care).

The national work programme contains the following focus areas:

• leadership – working with the to-be-established national strategic leadership group, and alignment with national and regional service networks
• models of care – supporting the implementation of accessible and nationally consistent clinical pathways for diabetes, CVD, stroke, and gout, along with developing a nationally consistent model for palliative and end-of-life care
• early identification – expanding equity-focused early intervention screening programmes in community and primary care for the priority conditions
• self-management and lifestyle support – this will include sector guidance and resources.

This mahi will set the direction for a future-focused approach, which will be developed and strengthened beyond the next two years.