Board 28.1.08
Item 8




                                      Long Term Conditions Strategy


Purpose of Paper :
This pap...
Long Term Conditions Strategy

  December 2007



Contents
Long Term Conditions Strategy.....................................
Patient empowerment .........................................................................................................
Long Term Conditions Strategy
Introduction
Definition
A long term condition is any condition with which a person has to li...
•    Seventeen and a half million people in this country report a long term condition (such as
         diabetes, asthma o...
4. Self care
Patients with a LTC have a plan in place and are encouraged and supported in managing their
own condition wit...
12. Support for family and carers
Carers of patients with a LTC are to have access to appropriate support and services tha...
Figure 2        Australian Chronic Disease Model




Figure 3         Kaiser Permanente Model




                        ...
Stockport Long Term Condition Model of Care

The model proposed for Stockport is based on the Australian model and is defi...
Patient Centred Care

One of the key issues is to integrate the elements of care and to develop a service that is patient
...
Well population
Prevention
Promotion of healthy life style
Smoking
Weight management - Diet & Exercise
Alcohol
Well being
...
Mothers, infants, young people:
The department contributes to the Children and Young People’s Strategic Plan with the aim ...
Promoting mental wellbeing/empowerment
The concept of wellbeing is important to the management and prevention of long term...
The team has also worked closely with the council supporting local businesses and residents to
comply with the smoke free ...
At Risk population
Prevention and detection
Screening
Case finding and health examination
Early intervention
Risk factor m...
Patient empowerment
All interventions require delivery in the context of the person’s wider social situation. Experience
f...
Established disease
Disease management
Disease management
Self care
Maintain risk factor reduction

Disease management
GMS...
Self Care
There is an Expert Patient Programme. This is small in scale at the moment when compared to
the number of patien...
Developed disease
Disease management
Hospital admission / discharge
Continuing care
Intermediate care
Case management
Care...
The service can support the patient during transition into a longer term placement either in their
own home with a package...
Social support
Experience from Case Management has shown poor mental wellbeing, often secondary to social
isolation, can c...
DATA

A full needs assessment has been undertaken for long term conditions and is included in the
appendix.

This assessme...
SERVICE GAPS

There are a range of areas where there is work planned and under way. The strategy in no way
wishes to stop ...
At risk population
There are gaps in service in relation to a number of aspects in this area.

Case finding
Case finding i...
patient centred approach promoted in the DoH framework. There is a need to negotiate a care
plan with a patient that cover...
Developed Disease

Case Management
The targets set out in the DoH framework for the management of long term conditions,
“S...
Case management has been established in Stockport. The learning from this has been useful
and is being used to review the ...
Project                                    Evidence base
Call Centre               Approximately 26 trials have reviewed t...
Resources
  Project             Description                  Place of delivery               Lead         Timescale

Call ...
Resources
  Project              Description                     Place of delivery               Lead           Timescale
...
Resources
  Project               Description                   Place of delivery                Lead           Timescale
...
Appendix 1

Strategy Development
Public Consultation
This strategy has been developed with the inclusion of the views of p...
Appendix 2

Long-term Conditions – Needs Assessment

1. Introduction

Whilst there is no definitive source of information ...
Stockport this equates to around 34,000 people aged 65 and over, and 42% of men and 46% of
women reported that their illne...
The 2001 Census showed that prevalence of limiting long-term illness within Stockport increased
sharply with age, with ove...
Long Term Conditions - RR
Long Term Conditions - RR
Long Term Conditions - RR
Long Term Conditions - RR
Long Term Conditions - RR
Long Term Conditions - RR
Long Term Conditions - RR
Long Term Conditions - RR
Long Term Conditions - RR
Long Term Conditions - RR
Long Term Conditions - RR
Long Term Conditions - RR
Long Term Conditions - RR
Long Term Conditions - RR
Long Term Conditions - RR
Long Term Conditions - RR
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Long Term Conditions - RR

  1. 1. Board 28.1.08 Item 8 Long Term Conditions Strategy Purpose of Paper : This paper reviews the literature, current measures in place to address long term conditions and activity data and defines the model that will be used to develop long term conditions for the future in Stockport and identifies the initial work programmes. Human Rights Act, Disability Discrimination Act, Equal Opportunities Act Issues: Health Benefit/Health Gain: Good management, starting from prevention of long term conditions, will improve health and reduce the burden of disease NHS Plan, National Policy or HIMP Issues : Good management of long term conditions is a national target area. ‘Sub Stockport’ Geographic or Population Group Issues: Resource Implications: As this is a strategy document there are no financial implications directly attributable to this document. There are a range of actions identified some are currently funded and identified as such. Other work plans will require the development of business cases to secure their funding. Committees previously discussed or agreed at: Committee LTC group Date 11th November SMCC board November PEC November Action Requested: Members are asked to support this approach to the management of Long Term Conditions Contact: Roger Roberts - 426 5570 Created by RRoberts Last printed 08/01/2008 8:48 a1/p1 1
  2. 2. Long Term Conditions Strategy December 2007 Contents Long Term Conditions Strategy.......................................................................................................4 Introduction..................................................................................................................................4 Definition..................................................................................................................................4 National Position......................................................................................................................4 The Strategic Approach................................................................................................................5 Principles for the Management of Long Term Conditions.......................................................5 The Proposed Model of Care........................................................................................................7 Underpinned by Health Promotion and Wellbeing..................................................................8 Stockport Long Term Condition Model of Care..........................................................................9 Patient Centred Care...............................................................................................................10 Current Situation .......................................................................................................................10 Introduction............................................................................................................................10 Well population......................................................................................................................11 Promotion of Healthy Life style.........................................................................................11 Promoting mental wellbeing/empowerment.......................................................................13 Weight management ..........................................................................................................13 Smoking cessation..............................................................................................................13 Alcohol...............................................................................................................................14 Sexual health.......................................................................................................................14 Professional support...........................................................................................................14 At Risk population..................................................................................................................15 Screening people at risk of disease.....................................................................................15 Routine Case Finding and Health Examination ................................................................15 Early intervention when disease is detected.......................................................................15 Created by RRoberts Last printed 08/01/2008 8:48 a1/p1 2
  3. 3. Patient empowerment ........................................................................................................16 Risk factor management.....................................................................................................16 Established disease.................................................................................................................17 Disease management..........................................................................................................17 Self Care.............................................................................................................................18 Maintain risk factor reduction............................................................................................18 Developed disease..................................................................................................................19 Continuing care ..................................................................................................................19 Case management...............................................................................................................19 Intermediate care................................................................................................................19 Hospital admission / discharge...........................................................................................20 Carer Support......................................................................................................................20 Palliative care.....................................................................................................................20 Social support.....................................................................................................................21 DATA.........................................................................................................................................22 SERVICE GAPS........................................................................................................................23 Well Population......................................................................................................................23 At risk population...................................................................................................................24 Established Disease................................................................................................................24 Developed Disease.................................................................................................................26 Work programmes......................................................................................................................27 Appendix 1.................................................................................................................................32 Strategy Development ...............................................................................................................32 Appendix 2................................................................................................................................33 Long-term Conditions – Needs Assessment...............................................................................33 Created by RRoberts Last printed 08/01/2008 8:48 a1/p1 3
  4. 4. Long Term Conditions Strategy Introduction Definition A long term condition is any condition with which a person has to live for the remainder of their life. It may or may not be ultimately fatal. For the purposes of this paper Long Term Condition Management is defined as “a system of co-ordinated health care interventions and communications for populations with long term conditions in which patient self-care is significant”. The needs of children are addressed in a separate review. National Position The DoH have issued their framework for the management of long term conditions in “Supporting People with Long Term Conditions” which lays out an NHS and Social Care model to support local innovation and integration. This clarifies the terminology for the different elements of care and sets a range of targets: • Focus initially on the very high intensive users of secondary care services through a case management approach. • Appoint community matrons to spearhead the case management drive. In total, there will be 3000 community matrons in post by March 2008. • Over time, develop a system of identifying prospective very high intensity users of services. • Establish multi-professional teams based in primary or community care with support of specialist advice to manage care across all settings. • Develop a local strategy to support comprehensive self care. • Implement the Expert Patient Programme and other self care programmes. • Take a systematic approach that links health, social care, patients and carers. • Use the tools and techniques already available to start to make an impact. The Public Health White Paper ‘Choosing Health’ underpins the entire long term condition approach. Also recently published are the papers titled “Supporting patients with long term conditions to Self Care” and “Our Health Our Care Our Say”. Both these papers build upon the theme of care for patients with long term conditions. The latest paper “Commissioning framework for health and well-being” confirms the issues in the earlier papers and promotes a way of health and social care commissioning for these services. In each of the papers the messages are similar requiring choice for patients. To make this possible they have to have good information on a range of services available, near home, at times convenient to them. To do this it is repeatedly proposed that patients or their representatives are to be included in the planning of services. To manage the increasing demand on services created by this approach self care is highlighted as key to helping patients manage their own conditions and prevent themselves becoming ill. The scale of the problem Created by RRoberts Last printed 08/01/2008 8:48 a1/p1 4
  5. 5. • Seventeen and a half million people in this country report a long term condition (such as diabetes, asthma or arthritis). This is 82,000 in Stockport. • For some people, especially older people and those with more than one condition, discomfort and stress is an everyday reality. • The impact on the NHS and social care for supporting people with long term conditions is significant. • Care for many people with long term conditions has traditionally been reactive, unplanned and episodic. This has resulted in heavy use of secondary care services. • Just 5% of inpatients, many with a long term condition, account for 42% of all acute bed days. The target • There is a national target to reduce inpatient emergency bed days by 5% by March 2008 using 2003/04 as the baseline. In Greater Manchester this has been stretched to 6.4% • Health communities are expected to make progress towards the target from 2005 onwards by offering a personalised care plan for vulnerable people most at risk. • There are a range of recommendations within “Choosing Health”, “Our Health Our Care Our Say” and the “Self Care” papers. Although there is undoubtedly this large group of patients out there, we do not know which ones are the ones at risk of moving up from one level of care to another. Work is required to stratify people so that plans can be developed to address the specific needs of particular groups. The Strategic Approach Principles for the Management of Long Term Conditions. The initial phase in the development of the strategy was the writing of a set of principles. These were consulted upon with a range of patient and carer groups. Further information on patient consultation is described in appendix 1. These principles must be seen in the context of collaborative working between all partner organisations including health, local authority and the voluntary sector and working within the evidence base. 1. Prevention People at risk of long term conditions are identified and provided with support, advice and information to prevent or delay the onset of that condition. There is systematic risk factor screening and proactive support for patients requiring support in modifying their lifestyle. 2. Patient identification People with disease will be sought to ensure that they are identified and appropriately treated. Prevalence data will be used to validate that appropriate levels of disease are identified. Stratification tools will be used to assist in segmenting the population to enable planning and provision of targeted services. 3. Person centred care People with a LTC are assessed personally taking into account the condition(s) they have with an aim to reduce the fragmentation of care. This includes a review of their social circumstances and, where indicated, a referral is made for carer review and welfare rights. A plan is developed with them, their family and carer and an annual reminder/review is arranged to update the plan if required. Created by RRoberts Last printed 08/01/2008 8:48 a1/p1 5
  6. 6. 4. Self care Patients with a LTC have a plan in place and are encouraged and supported in managing their own condition within the parameters they are able to manage and with triggers for when they then need to seek further support. A plan of how and what to offer in terms of information should be developed 5. Emergency and Acute Management People with an acute episode needing hospital admission or other acute provision for a LTC are treated in a timely manner by teams equipped to manage the possible multiple conditions that the person may experience besides the condition with which they are admitted. On admission to hospital good detailed information is supplied, where available, at the time of admission or as soon after admission as is possible. Where this is a planned referral high standard of referral information is supplied prior to the patient being seen. 6. Hospital Discharge Patients with a LTC have a planned discharge and are discharged with appropriate support and understanding where they are in the management of their condition(s). Their plan is to be updated quickly on discharge to ensure their return to being self caring as soon as possible. This plan will be communicated quickly to all relevant people including carers and service givers. The plan should be written and a copy issued to the service givers and the patient/carer/family before discharge. The plan should contain contact details over 24hours to report any failure to deliver on the plan. A plan should be developed to meet shortfalls immediately as this may result in re-admission. A mechanism needs to be developed for individuals to measure the performance of the services received on this plan for forwarding to the commission(s) 7. Rehabilitation People who have had an acute episode have access to appropriate rehabilitation and support to enable them to regain the maximum level of independence they are able to achieve and desire. 8. Provision of equipment People with a LTC are able to access the equipment and aids they require to lead as normal a life as possible. 9. Housing and accommodation There should be sufficient access to the type of housing that is required to maintain independent living for as long as possible and as desired by the patient. This is outside the remit of the NHS. 10. Personal Care and Support A person with a long term condition(s) should have access to information about their condition, information about the different means of support available to them and be involved in the processes deciding on the level of personal care required for them to maintain maximum choice about an independent life at home. A mechanism will be developed to assess the effectiveness and standards of this provision by the person/family /carer receiving the service(s) 11. Palliative Care Palliative care and general services are able to support those patients with a LTC who, as they approach the end of life, require specialist or more intensive support. They should have support in the management of symptoms, the relief of pain, meeting of personal needs, social and psychological and spiritual support. Created by RRoberts Last printed 08/01/2008 8:48 a1/p1 6
  7. 7. 12. Support for family and carers Carers of patients with a LTC are to have access to appropriate support and services that recognise their needs both in their role as carer and in their own right. The GPs will be expected to be able to demonstrate the patients in his/her practice with LTC by level of severity, the carers offering support to patients with LTC in the practice and the patients in the practice population who are carers of people outside the practice with LTCs. The practice should have a plan of how to monitor these groups to ensure that they receive appropriate information and access to other professionals, relevant voluntary and self help organisations and educational courses with an aim to reduce deterioration and ensure maximum quality of life for the person with LTC’ and their families/carers. The Proposed Model of Care The model of care proposed is one described by the Australian Health Authorities for the management of long term conditions and is summarised in figure 2. It covers the well population and the prevention strategies that are required through to the population with active long term disease and the health care they require. It also highlights the importance of health promotion interventions in reducing movement from one sector to the next. This model builds on the Kaiser Permanente model, figure 3 that is widely used in the NHS and provides a more comprehensive picture of the levels of intervention required. The three classifications used by the Kaiser model being Self Care, Care Management and Case Management. These apply to the established disease and controlled chronic disease sections of the Australian model only. The other two groups sit below the Kaiser triangle in the Health Promotion and Wellbeing section. It is therefore proposed that the two models taken together present a more complete picture. The importance of the management of Health Promotion and wellbeing is further described in the Australian model as seen in figure 1. There is good evidence that factors including sense of control, social support/inclusion and early life factors are important in the development of wellbeing. Figure 1 Health promotion Created by RRoberts Last printed 08/01/2008 8:48 a1/p1 7
  8. 8. Figure 2 Australian Chronic Disease Model Figure 3 Kaiser Permanente Model Underpinned by Health Promotion and Wellbeing Created by RRoberts Last printed 08/01/2008 8:48 a1/p1 8
  9. 9. Stockport Long Term Condition Model of Care The model proposed for Stockport is based on the Australian model and is defined below. It is not very different to the UK model but promotes the area missing in the UK model – ‘prevention’. It outlines the areas of activity that relate to each level of care and approximate numbers of patients at each level. Figure 4 The Stockport model Well population At Risk population Established Developed disease Disease Prevention Prevention and Disease Disease detection management management Promotion of healthy Screening Disease Hospital admission life style Case finding management / discharge Smoking Routine health Self care Continuing care Diet examination Maintain risk Intermediate care Exercise Early intervention factor reduction Case management Alcohol Risk factor Palliative care Well being management Patient empowerment Proportion of population (rough estimate only) 210,000 75-85,000 5-10,000 As described the numbers of people with long term conditions or at risk of developing them is rising. One of the key factors has to be the empowerment of people to take charge of their own health and if a condition develops any condition they might have. There has been much review of the self management of patients and this is promoted as one of the key ways of reducing demand on services in the future. The WISE model below was published by the National Primary Care Research and Development Centre to address this issue. Figure 5 The WISE model Patient Professional Structure Strategy Improve information Change professional Improve access to service response Specific method Work with patients to Promote flexibility in Change access arrangements develop information that professional response  Use patient/professional is through contacts as a means of  Relevant  A patient –centred complementing efforts in  Accessible approach order to maximise the  Uses a combination  The negotiation of a effectiveness of disease of lay and traditional self-management management evidence –based plan with patients  Allow patients to self refer knowledge based on self evaluation of need. Created by RRoberts Last printed 08/01/2008 8:48 a1/p1 9
  10. 10. Patient Centred Care One of the key issues is to integrate the elements of care and to develop a service that is patient centred. In primary care there has been much work with the new GMS contract for GP practices to identify patients with, or at risk of, some conditions. Practices are then given incentives to provide specific evidence based interventions in the management of these conditions. The next step of development in the management of long term conditions is to integrate these interventions so that we are treating and empowering the patient and negotiating an agreed solution to their full range of conditions. Currently we may be managing diabetes, asthma and Parkinson’s disease at separate appointments for one patient confusing them with different sets of complex information and instruction. Current Situation Introduction There is considerable work already taking place in Stockport. The next section of the paper seeks to pull together these strands of service. There are a range of common features in the management of any condition, the three middle features being from the Kaiser model, and these are the headings used in the next section of this paper. The other headings however are required to complete the continuum of care:  Prevention  Patient Self care  Disease management  Case Management  Palliative Care Created by RRoberts Last printed 08/01/2008 8:48 a1/p1 10
  11. 11. Well population Prevention Promotion of healthy life style Smoking Weight management - Diet & Exercise Alcohol Well being Introduction Stockport has a wide range of primary prevention and health promotion programmes aimed at the common risk factors for key long term conditions and the social determinants of health. These include work streams around lifestyle issues such as physical activity, obesity, alcohol and substance misuse, tobacco use, mental wellbeing, sexual health and sustainable transport. The PCT Public Health Directorate’s approach is to work in partnership with other agencies and, through the Local Area Agreement, to develop strong health alliances to provide a multifaceted response to the complexity of lifestyle influences on health. Community services The Health Visitor service provides support to many patients in the promotion of wellbeing commencing with support to new mothers. This is important in giving the children a good start in life and maximise their future health and the mental wellbeing of the parents. The School nurses, with practice nurses deliver the immunisation service across Stockport. Practice nurses lead this work in children under school age and School nurses in the school age children. Healthy life styles are also promoted to young people in educational settings. Pharmacy Service The pharmacy is recognised in the new pharmacy contract as being a key site for the delivery of health promotion messages in both a campaign and targeted way. Health inequalities The prevalence of people living with long term conditions increases with levels of deprivation. Reducing inequalities in health is a key priority of the PCT. As part of the strategy to reduce health inequalities, the Public Health directorate has developed specifically designed interventions for the strategy’s 5 health priority areas i.e. major killers, CHD/cancer, tobacco, alcohol, obesity and mental wellbeing. There are Community Development Workers providing support to particular groups who find services difficult to access e.g. Ethnic groups and women suffering domestic violence. Promotion of Healthy Life style a) Life course approach A whole life approach is used to address the common risk factors across all life stages: mothers and infants, younger people, adults and older people based on the evidence which suggests that the development of long term conditions is due to the effects of cumulative and interactive exposures. The Public Health directorate has strategic planning for each stage. Created by RRoberts Last printed 08/01/2008 8:48 a1/p1 11
  12. 12. Mothers, infants, young people: The department contributes to the Children and Young People’s Strategic Plan with the aim for children in Stockport to be well cared for, healthy and able to make healthy choices. Programmes offered by the department include: • Projects to improve breastfeeding initiation rates, especially in areas of deprivation • National Healthy Schools Programme: Collaborative working with education department, local authority and private schools, school nurses on assisting Stockport schools to achieve Healthy Schools status as part of the national Healthy Schools Programme. • Dedicated health promotion adviser to address issues around childhood obesity. • Breakfast club programme. The breakfast club initiative is focused on schools with 20% or more free school entitlement. • Development of healthy snack guidelines for staff working with under 12s • Annual delivery of public health campaigns in various settings on breast feeding awareness and increasing children’s intake of portions of fruit and vegetables. • Specialist smoking cessation advisers linked to SureStart and maternity services. • Dedicated health promotion adviser to address issues around substance misuse. • Gathering of health intelligence to inform service developments – Young Peoples’ Lifestyle Survey being undertake autumn 2007 with results expected Spring 08. • School travel plans Adults and older people: This includes involvement with Stockport Health Improvement Partnership and the “ All Our Tomorrows” partnership for older people, which focus on issues that improve the quality of life for older people to enable them to live independently for as long as possible. Programmes offered by the department include: • Screening programmes: Breast and CVD • Cancer awareness campaigns: skin, bowel and breast cancers • Chlamydia screening is being developed • Initiatives around weight management: Schemes in areas of deprivation: Fruit and vegetable referral scheme. Delivering a programme of smoothie and cook and taste workshops. • Initiatives with Age Concern • Promoting sexual health – Dedicated health promotion adviser providing support and guidance to the PCT and other organisations on issues around sexual health. • Promoting mental wellbeing. Dedicated health promotion adviser providing support and guidance to the PCT and other organisations on issues around mental wellbeing. • see supporting self care for other programmes - Supported self care – Whole person approach To increase understanding of the different needs of different people in making sustained, healthier lifestyle choices, to enable the development of more effective services, the health promotion department is using social marketing techniques and is one of ten national pilot sites for this innovative approach. To address the problem of individuals’ support being fragmented across different services the Public Health directorate is developing a “one stop shop” Lifestyle Service. Created by RRoberts Last printed 08/01/2008 8:48 a1/p1 12
  13. 13. Promoting mental wellbeing/empowerment The concept of wellbeing is important to the management and prevention of long term conditions. This concept is complex and made up of a wide range of factors. Where a person has a good sense of wellbeing they are more able to make lifestyle changes, cope themselves with minor disease or manage disease at levels above that of a person with a low sense of wellbeing. • Arts on Prescription • Self Health at your library • Health Defenders: promoting health literacy Weight management Weight management and the reduction of obesity are key issues for the health service and are very relevant in Stockport. Promoting physical activity • Walking the Way to Health programme: short led walks aimed at people who have not been active for some time or who have a health condition that would benefit from physical activity. • PARiS: A physical activity health professional referral scheme operating in areas of deprivation. COPD/Cardiac Rehabilitation patients are not geographically restricted. • Joint Strategic Needs Assessment 2007 indicated this is an area for further investment. Interventions around obesity • The Big Club: Closed exercise session for people with BMI of >30. • “Keep it off for good”: 12 week support programme for people with waist measurement 34 inches and above ( women) 40”inches and above (men) • A more comprehensive service is being developed Smoking cessation A comprehensive, borough wide, smoking cessation service has been developed across 3 levels: • Intensive support from specialist core service staff for the most dependent smokers. This includes specialist provision for priority groups: pregnant women and routine or manual workers who smoke. • Intermediate services provided by trained staff in key settings • Increasing numbers of health professionals and other relevant practitioners providing brief opportunistic advice as a routine part of their daily duties, referring on where necessary to other parts of the service. As tobacco use is a key driver in the development of health inequalities, there are additional services provided in areas of deprivation. There is borough wide delivery of No Smoking Day campaign and it is identified as compulsory for all pharmacies to deliver this campaign as part of the public health element of their contract. Created by RRoberts Last printed 08/01/2008 8:48 a1/p1 13
  14. 14. The team has also worked closely with the council supporting local businesses and residents to comply with the smoke free legislation Alcohol The department is part of the Safer Stockport Partnership which introduced measures to reduce alcohol related violence and anti social behaviour, contributing to the development of stronger communities. A public health campaign at Christmas targeted younger people with advice on staying safe and healthy during the party season. Alcohol education in schools was boosted with a new teachers’ support pack. Sexual health The CASH service (Contraception and Sexual Health) provide prevention and support on sexual health issues. • Condom distribution service • Delivering a number of health campaigns and events throughout the year which focused on those experiencing the worst sexual health • Increasing outreach services available via Central Youth • Social marketing project on sexually transmitted infections and condom usage commenced in priority one area (Brinnington). Professional support • Information service for health professionals • Training offered on evidence base around lifestyle issues and supporting people to make sustained healthier lifestyle choices Created by RRoberts Last printed 08/01/2008 8:48 a1/p1 14
  15. 15. At Risk population Prevention and detection Screening Case finding and health examination Early intervention Risk factor management Patient empowerment Screening people at risk of disease A number of interventions are supported in primary care by the QOF especially Smoking cessation and in the future obesity. Smoking cessation interventions are also delivered via the community pharmacy. Stockport participates in all the national screening programmes listed below. These are important in the routine detection at an early stage when the chances of successful treatment are greatest. Breast Cancer www.cancerscreening.nhs.uk/breastscreen Bowel Cancer www.cancerscreening.nhs.uk/bowel Cervical Cancer www.cancerscreening.nhs.uk/cervical Diabetic Retinopathy www.nscretinopathy.org.uk Downs Syndrome www.nelh.nhs.uk/screening/dssp/home.htm Newborn Bloodspots www.newbornscreening-bloodspot.org.uk Newborn Hearing www.nhsp.info Sickle Cell & Thalassaemia www.kcl-phs.org.uk/haemscreening Routine Case Finding and Health Examination The GMS contract encourages practices to identify patients with a range of key diseases and then to list them for active evidence based management. Patients with hypertension are not in themselves ill but are at risk of other conditions, principally strokes. The QOF requires that these patients are monitored and their blood pressure is maintained within appropriate limits. Stockport runs an enhanced service to screen patients for increased risk of cardiovascular disease. All people over 35 years are invited for an appointment every five years to have their risk factors monitored e.g. blood pressure and cholesterol and managed when appropriate. In many practices there is a diabetes screen included in this appointment. Early intervention when disease is detected Once identified with a risk factor out of range or an early presentation of disease patients are now coded with that condition on their medical record and enter a call and recall service to offer them evidence based care to manage this condition. Created by RRoberts Last printed 08/01/2008 8:48 a1/p1 15
  16. 16. Patient empowerment All interventions require delivery in the context of the person’s wider social situation. Experience from Case Management has shown that social isolation can cause people who would otherwise be able to cope at home to refer themselves to hospital. This is therefore an important issue for the Health Service and social isolation can not be identified as a Local Authority issue alone. The new pharmacy contract supports self care, encouraging the purchase of medicines by patients to manage their own conditions. Locally this has been promoted through the development of a formulary to suggest the type of product to recommend in particular situations. The Pharmacy and surgery are encouraged to discuss this and agree the point at which the patient should be referred on to the surgery. This is being promoted through the GP/Pharmacy incentive schemes. The pharmacy contract also aims to integrate the provision of health promotion advice and signposting to other health services within the mainstream service. This is therefore open to all patients. There is strong provision of services by the third sector in Stockport. An example of where this provision is important is in mental health where some of the smaller organisations offering services provided by local people are less threatening and therefore may be better received. Age Concern provides handy man and shopping services, and many others, to enable people to remain at home living an independent life. This sector will become really important in the support of people self caring. The Public Health directorate delivers a number of programmes promoting and supporting self care e.g. Self Health @ your library. Increasingly patients with mild to moderate depression are encouraged to manage the issue themselves by working through programmes either on their own computer or at the local library. Risk factor management The Public Health directorate contributes to provision of consistent lifestyle advice and therefore encourages people to manage their own health. Reinforcement of these messages at all levels of the system is provided through training and ongoing support to the specific screening programmes and commissioning the delivery of brief interventions for staff from all healthcare and partnership organisations, business and voluntary sectors. A resource ‘Fit for Life’ covering the evidence base, relevant targets and practical actions staff can take to help patients in areas of lifestyle change has been developed for community staff. A web based public health network has been created to support people in their public work. Created by RRoberts Last printed 08/01/2008 8:48 a1/p1 16
  17. 17. Established disease Disease management Disease management Self care Maintain risk factor reduction Disease management GMS contract The quality and outcomes framework supports patients with established disease. The framework has driven a strong increase in the routine application of evidence based interventions in the management of patients with long term conditions. This requires GPs, Nurses and administration teams to work together to provide an efficient system. The problem that has arisen in some practices is that it has led to a fragmentation of care as patients have their diabetes managed one day and may be back the next with their asthma and again with another condition. This does not promote patient centred care and can be very confusing for patients who may then get confusing and opposing messages. It may lead to patients who work not attending repeated appointments due to the difficulties in getting time off work. In some cases this is due to the skill set of the nurse seeing that patient, who is not qualified to address the other conditions the patient might present. It is important that with the increase in numbers of patients with long term conditions that they are informed and involved in the decisions about what level of treatment they are going to undergo. In this way they are more understanding of their condition and able to manage better, calling on support later in the development of problems. Stockport is an area committed to training of new professionals in both nursing and general practice. It is at the forefront of the development of these skills for the future. Most professionals would aim for the patient centred service above but find themselves constrained by the demands of service delivery. In some cases patients are not ready to become so much part of the decision making process. This is therefore an important issue to be addressed in the future. Medication review There is a medication review service for patients who are at risk of social isolation provided through the medicines management department in the PCT. Referrals are taken from district nurses, GPs, Social Work staff and Age Concern. Pathway development Care Pathways are being developed in the hospital and community. They are being required as part of hospital contract specifications and will become important in Practice Based Commissioning contracts with other providers including provider services. Mental Health In mental health there is currently a low level of service in primary care with access to CBT and other support limited. There are however graduate support workers and CPN services available. Created by RRoberts Last printed 08/01/2008 8:48 a1/p1 17
  18. 18. Self Care There is an Expert Patient Programme. This is small in scale at the moment when compared to the number of patients with long term conditions. This is open to all and patients can self refer. Parallel to this are a range of disease specific courses being offered to patients. These include the Diabetes Xpert, pulmonary rehabilitation and cardiac rehabilitation. The diabetes course is open to all and accepts patient self referral, pulmonary rehab is only available on referral by the GP and cardiac rehab is only available for patient following an MI. The Pharmacy has long been the centre for patients to purchase their own medicines. The range of medicines that are available has been increased by the department of health over the last few years to encourage this form of self management. A formulary for the management of some of the most common conditions has been circulated to pharmacists in Stockport, their staff offered training in accordance with the formulary and a trial undertaken to encourage patients to attend the pharmacy and not the surgery where they go with the single aim of getting a prescription to avoid having to pay for medication. Maintain risk factor reduction There are a number of secondary/tertiary prevention and health promotion programmes linked to disease specific care management. These are in partnership with other organisations i.e. Phase IV Cardiac Rehabilitation Community Physical Activity Facilitator This scheme is designed to help reduce further CHD incidence by supporting the transition of patients from phase III to phase IV cardiac rehabilitation and assisting those individuals to achieve the targets in the CHD NSF. It focuses particularly on patients who have had an MI by providing information and opportunities for physical activity but also to make other lifestyle choices easier by signposting patients appropriately. The facilitator, in partnership with the Foundation Trust team, offers Sports Trust and Leisure Service staff opportunities to work with these patients, with the aim of increasing the patient choice of physical activity opportunities over the long term. Take Heart Community based exercise class for people in Phase IV cardiac rehabilitation Healthy Hospital The Public Health directorate is working in partnership with the Foundation Trust in developing a health promotion strategy in line with the WHO Healthy Hospital Programme and “standards for better health”. Care pathways have been developed and are being piloted on inpatient wards for both smoking cessation and weight management, systematically helping staff identify and manage patients’ needs in these areas. A further pathway is being developed to aid reductions in alcohol use. Created by RRoberts Last printed 08/01/2008 8:48 a1/p1 18
  19. 19. Developed disease Disease management Hospital admission / discharge Continuing care Intermediate care Case management Carer support Palliative care Continuing care There is a long established district nursing service providing support to many patients with long term conditions. There is a well established Community Rehabilitation Service comprising domiciliary physiotherapy and occupational therapy whose aim is to promote independence for people often, though not exclusively, with long term conditions. There are a number of groups of specialist nurses providing more specialist care for patients. Some of these work from the tier 2 service thus providing care at level 2 others work from a hospital base with consultants thus working at level 3. These teams include: COPD Diabetes Heart Failure Dermatology Paediatrics (Hospital based service) The Jointly funded community equipment service consists of the Wheelchair, Orthotic, Home Equipment Service and Independent Living Centre who work to support other services in preventing unnecessary hospital admissions and supporting patients on discharge from hospital. Case management Stockport is in the forefront of work in Greater Manchester in the development of the case management service to support patients at level 3 as defined by the DoH in “Supporting People with Long Term Conditions”. Intermediate care Intermediate care and the Rehabilitation at Home team provide up to 6 weeks of care to support long term condition patients through a crisis and aim to prevent admissions to hospital or facilitate a reduced length of hospital stay. The Local Authority provides an intermediate care service to support people in their own homes or in a short term residential setting. The service can be provided to facilitate early discharge from hospital where the person is medically fit and is also used to prevent inappropriate hospital stays. In addition the service is used to prevent long term residential care admissions or facilitate discharge from such placements. Created by RRoberts Last printed 08/01/2008 8:48 a1/p1 19
  20. 20. The service can support the patient during transition into a longer term placement either in their own home with a package of care or into a short term residential setting. This is a multidisciplinary team consisting of social workers, nurses, therapists and home support teams and it is managed by the local authorities’ adults social care department. Hospital admission / discharge The discharge liaison nurse screens people throughout the hospital in order to identify those that require complex follow up support from the DN service and makes appropriate arrangements. The Acute trust provides the Specialist Therapy and Rehabilitation (STAR) service this mainly supports younger head injury patients under 65yrs discharged from the Devonshire Unit. The RRATHS (Rapid Response AT Home Service) service for over 65 patients is provided by the PCT and Local Authority to support people in their own home at a time of crisis. The RAH (Rehabilitation At Home) and SHEDS (Stockport Hospital Enhanced Discharge Service) teams for patients over 65 years of age are jointly managed by the Foundation Trust, the PCT and Adult Social Care to facilitate early discharge from secondary care. These teams with the intermediate care services (not including the STAR team) are being formally pulled together into one coordinated service within the current older peoples service review. Carer Support It is important to note that many people with long term conditions rely upon the support of an informal carer often a member of the family. Without the support of these people the care services would not mange the needs of the population needing care. It is therefore important that the needs of this group are also recognised and planned for in the future. In Stockport the Local Authority provides a lot of support for this group through the SignPost organisation. This is supported by the GP contract that asks practices to identify carers, noting this for inclusion in future consideration of their care needs and also encouraging them to make contact with the Local Authority for such support and any appropriate assessment. There are situations where children become the cares of parents. These children will have some very specific individual needs above those of adults. It is even more important that these people are identified and appropriate support provided. Palliative care The Palliative care respite service provides support for carers looking after patients in the terminal phase of life. Patients access this service on referral by their GP. The District Nursing teams with MacMillan and Palliative care teams provide support to patients approaching the end of life. This is being supported by the care of the dying care pathway and the community pharmacy supply service for the medication. Services are delivered in partnership with the LA Created by RRoberts Last printed 08/01/2008 8:48 a1/p1 20
  21. 21. Social support Experience from Case Management has shown poor mental wellbeing, often secondary to social isolation, can cause people who would otherwise be able to cope at home to refer themselves to hospital. This is therefore an important issue for the Health Service and must be addressed by all partners who commission and provide services to the people of Stockport. Data would suggest that we have a high population of people living alone in the UK and that this will become increasingly important. The Local Authority commission, and provide, a wide range of services; home care, Social Work teams including hospital discharge social workers, meals on wheels, etc. A newer element of service is Care Call, part of Stockport Homes. Commissioned by adult services they provide telecare in conjunction with their existing vital call service. The vital call service is the button worn around the neck that can be used to summon help in the event of a fall or other problem. The telecare call system is where sensors are placed about the patient’s home. The call centre would be alerted if the patient got up in the night and did not return to bed after a reasonable time. The suspicion might be that the person had fallen. The aim of the service is to give the person the confidence to remain at home. Other elements of the Local Authority are also important in the maintenance of good health or reducing poor health. Housing is crucial to the wellbeing of the population. Ensuring high standards of housing will, for example, reduce damp that aggravates asthma; good insulation will reduce the cost of heating and ensure that elderly people do not develop hypothermia in cold winters. The development of Specialist provision in the form of sheltered housing and extra care housing are also important to patients maintaining their independence. Extra care housing is a big development area for Stockport in the coming few years. Debt is also an important factor for people and can lead to poor health, especially depression. The Local Authority has a vital role in the provision of these services and publicity of them to appropriate sections of the population. For older people who do not meet Fair Access to Care Criteria for a service from the Local Authority Age Concern are funded by the Local Authority to provide a service (Wellcheck) to assess the needs of the person and local services available to meet them. There is a strong third sector provision in Stockport although coordination of these with the statutory services could be improved. Created by RRoberts Last printed 08/01/2008 8:48 a1/p1 21
  22. 22. DATA A full needs assessment has been undertaken for long term conditions and is included in the appendix. This assessment confirms the large number of patients in Stockport reporting a long term condition that limits in some way their way of life. This was reported in the 2005 General Household Survey as 43,000 people over 16 and in the 2005 Health Survey for England 34,000 people over 65. The numbers of people with these limiting conditions increases with age and is higher in males in middle age moving to females in older age. There is a good match between the areas with higher levels of deprivation and areas with higher levels of reported disease that limits activity. The data on diseases experienced by people in Stockport is detailed in the needs assessment (Appendix 2). The needs assessment figure 3.1 shows the numbers of people with each condition, fig 4.1 the top conditions causing hospital admissions and fig 4.2 data on the ambulatory care conditions. These are presented in descending order of the top 10 conditions in each group in the following table. Ambulatory care Most frequent conditions Conditions causing admission admissions 1 Hypertension Chronic Heart Disease Dental 2 Asthma Chronic Obstructive Pulmonary ENT Disease 3 Chronic Heart Disease Diabetes Angina 4 Diabetes Stroke Chronic Obstructive Pulmonary Disease 5 Thyroid Heart Failure Flu/Pneumonia 6 Stroke Asthma Epilepsy/convulsion 7 Chronic Kidney Disease Chronic Kidney Disease Dehydration & GI 8 Chronic Obstructive Hypertension Diabetes Pulmonary Disease 9 Atrial Fibrillation Thyroid Heart Failure 10 Heart Failure Atrial Fibrillation Cellulitis From this data the top ambulatory conditions identified in Stockport that require attention are: • Diabetes • Epilepsy • Flu and dehydration • Chronic Obstructive Pulmonary Disease • Cardiovascular Disease These are therefore top priority for review and development Created by RRoberts Last printed 08/01/2008 8:48 a1/p1 22
  23. 23. SERVICE GAPS There are a range of areas where there is work planned and under way. The strategy in no way wishes to stop or delay this activity and in this section sign posts to where this work is being undertaken. There are other areas where work is required and these are identified for future consideration of the appropriate lead person. Future papers will be required to pick up these elements of work and further develop the strategy. The conditions listed above as being those that are top priority for Stockport are considered in each of the sections below. In many cases the service developments will be more generic than specific to the area identified but will contribute to the management of that service. The areas of the Australian model are used in the next section. Well Population Public Health is undertaking a service review and will assess the services available against the population needs. This will be reflected in the joint strategic needs assessment on which public health are taking the lead. Early areas of identified need for development are: • Alcohol brief intervention service • Lifestyle service • Weight management strategy • Health trainer project – initially linked to weight management project It must be noted that the investment criteria of “invest to save” are very difficult to apply to prevention interventions. Though prevention potentially creates massive savings they will not be evident for many years and are rarely able to be credited to the intervention made. Wellbeing The main elements of wellbeing are:  Keeping physically active  Eating well  Drinking in moderation  Valuing yourself and others  Talking about your feelings  Keeping in touch with friends and loved ones  Caring for others  Getting involved and making a contribution  Learning new skills  Doing something creative  Taking a break  Asking for help. It is important that these become more widely understood and are considered in the development of new and reviewed services. Currently there is work ongoing in this area in support of mental health services but to be fully effective this needs to become a more explicit part of service development in many areas and not become stigmatised as being mental health. Created by RRoberts Last printed 08/01/2008 8:48 a1/p1 23
  24. 24. At risk population There are gaps in service in relation to a number of aspects in this area. Case finding Case finding is incentivised through the Quality and Outcomes Framework (QOF) however there are a number of conditions not included in the QOF. These are not therefore receiving the same focus of attention. This is not the case with the priority disease areas Disease Prevalence There is a wide variation in prevalence across practices within any disease area in the QOF and this requires review to ensure that this is a justified variation. This is key in the management of the priority disease areas. Screening Screening is usually well taken up in Stockport but there are health inequality access issues to be addressed in relation to these services. Screening programmes are in place in accordance with national criteria. They are however developing and expanding. The introduction of a bowel screening programme is planned and the introduction of the HPV vaccine will alter the cervical screening programme in some years’ time. Social Isolation Social isolation can be significant as people become older and less able to travel. Schemes such as befriending schemes and the Gerbera scheme would significantly support this element of care. The Extra Care Housing developments proposed in Stockport will be important in addressing this element of care. This underpins the management of all disease and will be equally important to the management of the priority disease areas. The Carecall and telecare systems are developing and the local authority has a target to provide 750 service users with vital call alarms and other additional technology aimed at promoting independent living. This service needs to be developed with associated telehealth and the Carecall call centre developed with a plan to commission a joint service in the future. Consideration must be given to how the Carecall, Mastercall and BUPA call centres are integrated in the future to provide a single comprehensive service We need to explore the potential for stand alone telecare systems for informal carers. Adults social care fund a variety of services in conjunction with colleagues from the third sector aimed at providing practical preventative and low level support to help alleviate social isolation Established Disease For established disease and controlled chronic disease there is significant service in place however this can be uncoordinated. Care Pathways Care pathways are required to improve the level of integration of service. Care pathways however potentially increase the disease specific approach to health care as opposed to the Created by RRoberts Last printed 08/01/2008 8:48 a1/p1 24
  25. 25. patient centred approach promoted in the DoH framework. There is a need to negotiate a care plan with a patient that covers their spectrum of disease. They should not for example be given a plan for their asthma, angina and Parkinson’s disease separately. For the priority disease areas this is important as there will be many other conditions experienced by people with the priority diseases and they must be managed in the context of the wider health need. Patient Empowerment Patients need to become more empowered to manage their own care and the expert patient programme is well established in Stockport. This requires further development to get better attendance from all groups of the population. However the programme in place has recently doubled its capacity. In addition to this the early stages of disease specific education are emerging with the requirement by NICE to have education in place for new patients with type II diabetes. This approach to group teaching has also been used for cardiovascular management after a heart attack. In primary care this approach was tried for routine lipid management and anecdotally it did not create change at the time but caused some of the more resistant patients to return for a consultation to ask for treatment they had not previously taken. As the numbers of patients with conditions increase more of this group management will be required. More patient education must therefore be commissioned to support both the generic expert patient programme and the disease specific programmes for the more common conditions. This is required in both the extension of current programmes and the development of further programmes for other conditions. Patient Centred Care To make patient care patient centred a negotiated care plan is required. Most health professionals would say that this is what they aspire to achieve. Patients do not recognise this as the outcome of consultations and may not be ready for this style of approach. Work is therefore required on the style of consultation and the preparation of the patient for this type of discussion that would culminate in a written care plan with which they are willing and able to comply. This is being incentivised through the PBC incentive scheme but still requires significant development to become routinely used. Multi-professional Working To manage the numbers of people with LTC all members of the wider teams will need to play their part. One of these is the community pharmacist. In this setting the patient should be able to access the medication they require to manage most minor self limiting conditions without access to the doctor. This access is used less these days as patients have been trained that there might be something serious behind their symptoms and they need a doctor. There are also social pressures to access sick notes from the doctor. There has also been a reduction in public knowledge about how to manage many conditions themselves. Brief interventions to address lifestyle issues can often be made by a fellow member of the local community working in the pharmacy and with smoking cessation this has shown to be at least as effective as the message from the surgery. The pharmacy can also undertake low level medication reviews. In the future they will manage more often repeat medication for patients with stable conditions as repeat dispensing becomes available. This development is addressed in the PCT medicines management development plan. This will be important in the management of the priority conditions as well as many others. Created by RRoberts Last printed 08/01/2008 8:48 a1/p1 25
  26. 26. Developed Disease Case Management The targets set out in the DoH framework for the management of long term conditions, “Supporting people with Long Term Conditions”, are being addressed. The first three targets relate to the provision of the Active Case Management service and there are case managers in post with case loads developed from the PARR and Castlefield scoring systems to identify the high or potentially high intensity service users. There are services in place to manage patients with complex needs in a multi-professional way but this requires wider development. This service will support people with a wide range of conditions including the priority conditions identified. As one of the criteria is the number of patients with that disease this service will support many of the most severe patients with the priority conditions. Service Reviews. There are major service reviews taking place in Older Peoples service and Primary Care Mental Health services. These will contribute to this agenda significantly and this strategy will influence their development. It is also planned to review a number of services as defined in the 2007/8 business plan. Cardiology Podiatry Service. Stroke Services Health Visiting & School Nursing IVF Services District, ACM and Treatment Room Nursing Physiotherapy GP Out of Hours Contract CVD Screening Palliative Care Review Maternity Services End of Life Services GP input into Nursing Homes Voluntary Services Salaried dental service Limb fitting and support centre Telehealth Stockport Local Authority received funding from Central Government to fund telecare projects that are currently in place and expanding. There is a need to consider the opportunity to develop joint services linking in telehealth interventions. Telehealth would enable the patient to take a blood pressure, ECG or similar test and feed the results down a telephone line to the centre to ensure that all is well with their long term condition. There are also medication aids that can be linked to these systems that would identify if a person had taken their medication and remind them to do so. A call centre can however do much more in assisting the patient in their journey down a care pathway. Once a pathway is agreed the call centre can pilot the person reminding them at appropriate times to do things. Where a professional has established an individual plan for a patient the call centre can provide the follow up to ensure that this has been understood and is being implemented. Some development work is going on in Stockport on this type of intervention. This in time will need to link to the telehealth and telecare services described above. Created by RRoberts Last printed 08/01/2008 8:48 a1/p1 26
  27. 27. Case management has been established in Stockport. The learning from this has been useful and is being used to review the District Nursing Service. The approach of completing a detailed review of the person and their needs and addressing all needs including social needs has proved to be a good model. It is proposed to make this the outline for the District Nursing Service in the future and to move away from the task specific focus of recent times. Work is also planned to further integrate the work of the Health and Social Care teams to deliver the packages of need identified. This development will be of generic benefit to the priority conditions. Palliative Care At the end of life the current level of palliative care is limited and largely focused around cancer patients. This is recognised and plans are in place for it to become more widely applicable to include other conditions such as COPD and heart failure. The place of death is currently usually in hospital or in older age groups in care homes. Patients express the desire for this to more often be in their own home. There is significant work in place to develop the end of life pathway according to the GOLD standards and the Liverpool pathway. This development is described in the palliative care team’s action plan. Work programmes From the above description it can be seen there are a number of work plans already in place and these will continue. The details of these plans are contained in specific papers on these developments and will come through the relevant committees as they reach an appropriate stage of development. Created by RRoberts Last printed 08/01/2008 8:48 a1/p1 27
  28. 28. Project Evidence base Call Centre Approximately 26 trials have reviewed telephone support services and in broad conclusion they have improved outcomes and when used post discharge have reduced reliance on other health care services Telehealth There have been over 30 trials looking at telehealth and where coupled with telephone follow up with a clinician was most positive Health trainers Health Trainers are required by “Choosing Health” public health white paper. The intervention is based on a wide range of behaviour change research. LTC Enhanced Service This service is about better understanding the population and their level of risk to support future planning. When used to support service development the evidence is good for this work. There is also a simple intuitive targeting of activity to put in place plans to reduce avoidable hospital admissions. There is little evidence either way on the outcomes of such an approach Case Management The evidence for case management came from the States and has not been matched in the UK where the same model has been applied. In Manchester the model has been developed and there is some positive evidence for care in patients homes and provided by an integrated team that would indicate success. Personalised Care Plans There is little evidence that these used alone are beneficial Medication Review There is little evidence in this area but this workstream is about getting the best from the QOF and Pharmacy contracts to do this work. Locally where reviews have been done well they have saved the cost of the review at least twice. Patient Education There is evidence that patient education may move care from hospital to primary care Palliative Care Being developed to support the delivery of the Gold Standards Framework. Mental Health The Stockport developments are required by the Mental Health NSF and delivery of key targets.
  29. 29. Resources Project Description Place of delivery Lead Timescale Call Centre Pilot call centre with BUPA. To be delivered to a Jane Rossini & 6month pilot Pilot funded until May Patients with 8 major conditions population of 10,000 patients Roger Roberts commence 2008. Further funding will be supported over and through approx 12 practices August 2007 is being considered by above normal care through the SMC to maintain pilot call centre until end of March 2009 when the success of the pilot can be established. Estimated unconfirmed cost £135,000 Telehealth Companion project to support To be piloted with 20 Roger Roberts 12 month pilot Pilot funded by LA medication taking machines commence assistive technology January 2008 budget. Rollout to be reviewed on basis of pilot. 6 month pilot Joint funding PCT COPD telehealth project pilot Join PCT Mastercall pilot commence slippage and February 2008 Mastercall ECG done in practice and Enhanced Service Pilot complete Enhanced services interpreted by phone and service ready Pre-consultation questionnaires Pilot Pilot for 12 Slippage funding months commence Jan 2008
  30. 30. Resources Project Description Place of delivery Lead Timescale Health Prevention initiative providing 1 21 most deprived practices Jane Pilkington Contract let to Money identified in trainers to 1 behaviour change support provide LDP targeting December 2008 a) Clients aged 40-65 who are sub threshold for chronic disease Clients referred into weight b) Clients who are overweight management ICAT or obese as part of the weight management ICAT LTC To stratify patients over 65 To be piloted in two PBC Roger Roberts Sept 07 – LES funded for 2 Enhanced years of age and develop localities Oct 09 localities initially. Service capacity in primary care to manage patients at the stage before ACM to prevent onward development Case Intensive support for patients Available to all practices Clare Watson Currently in Funding identified in Management with multiple needs that might place and LDP otherwise lead to hospital developing admission Personalised PBC incentive scheme requires Delivered to all practices via Roger Roberts Financial year Incentive scheme Care Plans practices to develop personal incentive scheme 2007/8 funding identified care plans for patients. Standard templates are being developed Medication Medication review is required Delivered in small number Roger Roberts Financial year No funding required as Review by QOF and improvement in of pilot practices in 2007/8 2007/8 done within contract standard will improve reduction frameworks of medication waste. Patients taking 4 or more meds will have to have this face to face. Links with pharmacy MUR will assist in management of volume
  31. 31. Resources Project Description Place of delivery Lead Timescale Patient Expert Patient – Programme Open to patients from any Fran Holmes On going and Funding identified Education encourages patients with any practice expanded in condition to manage their own 2007/8 care Disease specific patient training for: Diabetes – Xpert programme Trialled and opening up to all Tracy Hancock Pilot complete To be commissioned in 2007/8 and rollout Sept and funding required 07 LPD bid being developed COPD – pulmonary rehab Via tier 2 service Karen FernOngoing to expand in Funding to be 2009/10 identified Obesity – Keep it off for good Delivered through public Gill Dickinson On going Funding identified - Slimming World health To be piloted in 2007 Asthma To be commissioned Roger Roberts To develop in 2008/9 Palliative Palliative care strategy is being Jointly across primary and Dr David December 2007 To be identified Care developed This will have a secondary care. Waterman through palliative care number of associated work strategy streams Mental Health Review of the primary care PCT review Gina Evans Implementation Identified in LDP mental health service 2008 Older People There is a major service review of older peoples services underway leading from the review of Cherry Tree services and this links very strongly with the provision of long term conditions services for this group of patients. The detail of this review is however addressed in other papers. This work stream is led by Maggie Keufeldt
  32. 32. Appendix 1 Strategy Development Public Consultation This strategy has been developed with the inclusion of the views of patients in Stockport. The principles were circulated to a range of patient groups that represent patients with long term conditions and they were asked to comment on these. They were further invited to report the three top issues for them under each principle area and these have been built into the action plan where possible. There was little response to this communication and the comments received are available for view. The strategy has now been circulated for further discussion and a group will be established to monitor the action plan development for the range of projects in the strategy and serve as a reference group for the project leads.
  33. 33. Appendix 2 Long-term Conditions – Needs Assessment 1. Introduction Whilst there is no definitive source of information about the number of people in Stockport who have a long-term condition there is a range of evidence we can use to estimate the prevalence of these conditions and likely trends over time. This process however, is complicated by the fact that there are many different long-term conditions, some of which co-exist within the same patient, and that there are varying degrees of evidence for each condition as to the extent of the problem within Stockport. 2. Overall Prevalence 2.1. Overall prevalence National evidence presented within the NSF for long-term conditions suggest that 17.5 million people in the United Kingdom (approximately 30% of the total population) live with a long-term condition; by the time people reach the age of 75 the proportion increases to over three-quarters (DH 2001). If extrapolated to Stockport these national figures suggest that around 82,000 people in the borough have a chronic health problem of who over 17,000 people are aged 75 years or above. Other sources of evidence for the overall prevalence of long-term conditions within the population are severely limited and therefore the subsequent analysis relies on proxy measures. The 2005 Health Survey for England, which concentrated on the health of those aged 65 years and above; stated that “longstanding illness is an important indicator of the general health of the population. It indicates need for health and social services” however the report notes that “it is important to remember that data based on the informants’ subjective view may not necessarily correspond to medical diagnoses...[indeed] there is evidence that people rate their health in different ways: some think in terms of health behaviours or physical functioning and others consider specific chronic health problems such as diabetes that affect morbidity. There are also marked differences in the assessment of health between the sexes.” Despite these warnings it is one of the few useful and comprehensive measures of health status available at the local level. Evidence from the Welsh Health Survey 2003/04 suggests that levels of limiting long-term illness are lower than reported levels of chronic conditions at all ages, and although the data from this survey cannot be directly applied to Stockport the general implication of the trend, i.e. that reports of limiting long-term illness are likely to underestimate the prevalence of chronic conditions, should be borne in mind with the following analysis. The 2005 General Household Survey, which focuses on people in Great Britain who are aged 16 years and above, asked people to report whether they had a long-standing condition, and whether or not any condition limited their day to day activities. 33% of respondents stated that they had a long-term condition, and 19% reported that they lived with a limiting condition; extrapolating these figures to Stockport this gives estimates of 75,000 people aged 16 plus with a longstanding condition and 43,000 people aged 16 plus whose condition limits their lives. The results of the 2005 Health Survey for England shows that both men and women aged 65 and over reported the same prevalence of limiting longstanding illness or 71%, extrapolating to
  34. 34. Stockport this equates to around 34,000 people aged 65 and over, and 42% of men and 46% of women reported that their illness limited their activities in some way; approximately 20,000 people aged 65 plus locally. The prevalence of longstanding illness and limiting longstanding illness increased with age in both sexes (see section 2.2) and the prevalence of self-reported longstanding illness and limiting longstanding illness was lower among informants with higher income (see section 2.4). The Health Survey for England however does not provide comprehensive data for those aged under 65 years of age nor is it reliable at the local area level. The 2001 Census of Population was the most recent comprehensive survey conducted within Stockport which posed questions about long-standing illness in the borough. Results showed that 17.7% of the resident population of Stockport (50,300 people) described themselves as having a long-term illness which limited their day-to-day activities; a number which is well below the estimate of 82,000 outlined above but much closer to the estimate from the General Household Survey of those with limiting illness. Unsurprisingly rates are much higher for those in communal establishments (87.2%) as compared to household residents (17.1%), although only around 2,000 of the total population are reported to live in these institutions. Further in-depth analysis of the 2001 Census results by age, gender and deprivation is presented in sections 2.2 to 2.4 below. 2.2. Overall prevalence by age Older people make up an increasing proportion of our population. Nationally since the early 1930s, the number of people aged over 65 years has more than doubled and is continuing to rise. In Stockport in 2001, 16.6% of the population were aged 65 and over; this is forecast to rise to 18.1% by 2011, with a projected increase of more than 1,000 people aged 85 plus over the decade. Although average life expectancy is increasing in the borough, improvements in mortality may not necessarily be reflected by improvements in morbidity. These changes in population characteristics could lead to increased demand on health services, especially if age specific prevalence of morbidity described below remains constant or increases while the number of older people rises. Figure 2.1: 2001 Census of Population - Limiting Long-term Illness 90% 81.9% 80% 72.4% 70% 63.9% Proportion reporting a LLTI 60% 53.4% 50% 42.7% 40% 36.6% 32.4% 30% 25.4% 18.8% 20% 14.3% 11.6% 9.3% 10% 6.6% 7.6% 6.1% 4.6% 4.4% 4.5% 3.0% 0% 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90+ Age Group
  35. 35. The 2001 Census showed that prevalence of limiting long-term illness within Stockport increased sharply with age, with over 75% of those aged 85 years and above reporting having such a condition (see figure 2.1), again rates for residents of communal establishments were much higher than those of household residents (93.1% and 72.% respectively). However although the prevalence of limiting long-term illness followed an age profile it is worth noting that of the 50,300 people with a limiting long-term illness only 4,200 (8.3%) were aged over 85 years due to the low population size at this age (see figure 2.2). The majority of people with limiting long term illnesses were aged between 60 and 79 years, around 20,000 people or 40% of the total. At the other extreme of the age scale around 3,000 children and young people aged under 20 years and 2,000 people in their 20s in Stockport were identified as living with a limiting long-term illness (see figure 2.2). Figure 2.2: 2001 Census of Population - Limiting Long-term Illness 6,000 5,254 5,092 5,000 4,814 4,820 4,221 4,076 3,903 People reporting a LLTI 4,000 3,000 2,693 2,725 2,354 2,137 2,000 1,683 1,455 1,105 1,000 827 863 804 759 488 0 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90+ Age Group 2.3. Overall prevalence by gender 54.7% of those reporting a limiting long-term illness were female, a figure slightly higher than the average population split of 51.7% but reflecting the greater longevity of women. For similar reasons females reported a higher overall rate of limiting long-term illness than males (18.6% and 16.5% respectively) and both males and females followed an age profile of increasing levels of illness (see figure 2.3). Similar proportions of both genders experienced illness at ages under 60 years; however during ages between 60 and 69 years males are more likely to report a limiting condition than females. For those in their 70s the rates are again comparable between men and women however once over the age of 80 years females are more likely to live with a limiting illness, indeed for those aged 90 and over 83.1% of women reported a limiting condition compared to only 76.9% of men.

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