Long Term Conditions


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Long Term Conditions

  1. 1. LTC South West Ambitions
  2. 2. DISCUSSION DOCUMENT Prevalence of specific long-term conditions Prevalence of Long-Term Conditions known to GPs through QOF As part of the Quality and Outcomes Framework (QOF) GPs are rewarded for compilation of registers of the prevalence of certain long-term conditions. These registers show that almost one in eight people in England are being treated/monitored for hypertension and one in seventeen people are being treated/monitored for asthma. Prevalence of QOF conditions, 2005-06 14% Unadjusted Prevalence (% of population) 6.37 12%NHS Next Stage Review 10% 8% Prevalence in millions 3.1 6% 1.9 1.89 4% 1.26 0.73 0.83 2% 0.38 0.32 0.23 0.32 0% Asthma Cancer COPD Coronary Heart Diabetes Epilepsy Hyper-tension Hypo-thyroidism Left Ventricular Mental Health Stroke and TIA Dysfunction Disease * QOF Condition Source: Quality and Outcomes Framework 2005-06, Health & Social Care Information Centre 5
  3. 3. South West• Five million population• 17.4% registered with LTC (870,000) Most Recent Census• 70-74 39.9%• Over 90 74.1%
  4. 4. Immediate Areas for Improvement• Promoting health, disease prevention and self-care• Meeting the 18 week target for elective referral and providing fast track services for urgent referral• Reducing emergency admissions and delayed transfers of care• Further improving stroke services• Improving mental health services for older people, including dementia care• Making available assistive technology and equipment• Improving dignity in care in all settings• Providing access to appropriate palliative care services
  5. 5. Local Examples of Best Practice• Partnerships for Older People Projects• Cornwall and Isles of Scilly falls prevention and management• ‘Look after your legs’ initiative in Gloucester,• Age Concern in Devon to provide mentoring to isolated older people• Fast track services in Bournemouth and South Devon, for people suspected of having a stroke;• use of the FAST (Face-Arm-Speech-Test) scheme in Cheltenham
  6. 6. Local Examples of Best Practice• Improving housing pathways work in Plymouth• Pathways to Work Somerset• Telecare programme in Gloucestershire• Expert carers programmes, for example in Bath and North East Somerset
  7. 7. Headings and Challenges• Prevention• Early Detection• Proactive and Integrated Care• Self Care• Specialist Care• Rehabilitation
  8. 8. Prevention• local identification and ownership of the needs of the community: Ensuring the Joint Health and Social Care Needs Assessment, being undertaken by Primary Care Trusts and Local Authorities across the South West, links effectively with local communities;• organisational planning cycles: Ensuring alignment of planning timetables for Local Area Agreements and Local Delivery Plans;• shift in funding: Achieving flexible approaches to use of health and social care funding to support the prevention agenda, ensuring this is underpinned by strong governance arrangements.
  9. 9. Early Detection• health inequalities: Ensuring information, personal to circumstances, in range of styles and formats, is accessed by all social groups especially those in areas of deprivation• access to diagnostics: Improving direct community based access to diagnostics with view to improving early identification and management of long term conditions and resulting in a subsequent decrease in number of referrals to secondary care specialist services
  10. 10. Self Care• system change: Ensuring the concept of self-care is fundamental to all long term condition services and interventions;• information and advice: Making information and advice available in local communities in a way that will encourage access by individuals to support self care;• professional understanding: Professional attitudes and comments made to patients can, if solely based on a ‘medical’ model, be detrimental to promotion of self care
  11. 11. Proactive and Integrated Care• policy direction: Management of tensions between differing government policies and minimising the risk this presents to achieving a whole systems approach;• organisational boundaries: These may include: • differing organisational priorities including investment priorities; • barriers between primary and secondary care; • differing understanding of concepts and use of language between organisations;• capacity and capability: This includes supporting the development of the third sector• addressing rurality: Minimising the impact of rurality issues on equity of access to services
  12. 12. Specialist Care• commissioning flexibilities: improving flexibility to commission for whole needs of an individual i.e. beyond health care• professional specialisms: Professional specialisms can foster a continued adherence to a medical model for long term conditions• location of specialist care: Location of specialist care is currently to a large extent within acute hospital settings and does not support the shift to localised care in the community and the concept of empowering the individual to manage his or her own condition• data systems: Current data systems are not always in line with current and planned models of care
  13. 13. Rehabilitation• perception of rehabilitation: community based bio- psychosocial rehabilitation model including community, social and voluntary services• long term condition skills base: Ensuring community services achieve the critical mass required to achieve and maintain disease specific skills within the workforce, whilst retaining a patient-centred approach to care• current rehabilitation model: Most rehabilitation models and services operate within office hours, have limited availability out-of-hours, are often only available in an inpatient setting, and within limited timeframes, for example six or nine weeks
  14. 14. Concepts
  15. 15. All Partners Public services, Voluntary organisations, faith communitiesHealth,social care,housing
  16. 16. Vision of for LTCs Community Input Social Input Specialist Input Medical InputCommunity Community owned owned Care Pathway Health Health Care Pathway Inequality Data Campus Care Pathway
  17. 17. LTC Ambitions• Ambitious re-alignment of our engagement with LTC to reflect the change of direction in acknowledging the patient as being the locus of control for the condition with which they are living on a day-to-day basis• Health services should align themselves around this patient rather than fitting the patient around the health service
  18. 18. A joint health and social care commissioning strategy• plans for raising awareness of individuals and communities around local health issues• provision of good early information• local initiatives which support people to access healthy lifestyles• structures and protocols for early detection and screening• mechanisms agreed by which practice-based disease registers can inform local commissioning and planning• structures to support specialist provision closer to peoples homes• plans for structured approach to commissioning from voluntary sector
  19. 19. Metrics
  20. 20. 1. Community HNA• at least one local community within each Primary Care Trust area has become engaged in their own heath needs analysis in at least by September 2008
  21. 21. 1. Health Campus• each area has developed at least one Health Campus based on the Community Health Model through which lay people become the local resource for their population
  22. 22. 1. Self Management Plans• 75% of patients with one of the more common long term conditions will have been offered an action plan that supports self management, by March 2009 – patient centred goals and outcomes – describes what carers, agencies and professionals will do – supports individuals to cope with exacerbations, crisis and changes
  23. 23. 1. General Practice• over 75% of general practices to have adopted the self care policy for their locality by July 2009
  24. 24. 1. Single Point of Access• all Primary Care Trusts to establish a single point of access or coordination system by which they support their long term conditions Health Campus to ensure existing range of services both statutory and voluntary are accessed appropriately by people with long term conditions by March 2010
  25. 25. 1. Community Based Services• all Primary Care Trusts to review existing community based services to ensure a coordinated multidisciplinary team approach to the management of long term conditions, reflecting local need and part of a managed network of care, by 2010
  26. 26. 1. PBC and the Public• Practice Based Commissioners will have infrastructure in place through which patients with long term conditions are fully involved in the commissioning of their own services including the development of choice where appropriate by March 2009
  27. 27. 1. Specialist Services• specialist input to long term conditions will be re-specified from the community perspective for at least three conditions by April 2009
  28. 28. 1. Public Experience Surveys• performance management metrics will be developed locally for each long term conditions based on individual surveys of patient experience in addition to more traditional process markers