For those with long term conditions it is important to ensure that we not only add years to life, but add life to those years. Looking across the specialties NHS Improvement works with we have identified four key areas across the pathway where patients and carers want improvements: - Stabilising the condition to get patients back to living their lives - Supporting patients to live their lives through monitoring and review - Timely intervention to the appropriate service when things go wrong - Providing choice and support towards the end of life

1. NHS NHS
NHS Improvement NHS Improvement
SUMMARY NHS Improvement INTRODUCTION
NHS Improvement’s strength and expertise lies in practical
service improvement. It has over a decade of experience in
There is a need to shift from an organisational CANCER NHS Improvement has over eleven years’ practical
clinical patient pathway redesign in cancer, diagnostics, heart,
model of delivery to a pathway approach which experience in key clinical specialties to redesign
lung and stroke and demonstrates some of the most leading
pathways of care that support effective and timely care
focuses on the needs of individual patients. This edge improvement work in England which supports improved
delivery. For those with long term conditions it is
will require an improvement in data quality across patient experience and outcomes. important to ensure that we not only add years to life,
DIAGNOSTICS
hospital, primary care, community and social care but add life to those years.
Working closely with the Department of Health, trusts, clinical
so that we can analyse the data to determine what networks, other health sector partners, professional bodies Looking across the specialties, NHS Improvement works
services need to be provided and determine the and charities, over the past year it has tested, implemented, with, and talks to, patients and carers. As a result of
competencies required for staff and carers to sustained and spread quantifiable improvements with over HEART
this, four key areas have been identified across the
250 sites across the country as well as providing an pathway where patients and carers want us to get it
provide and support the delivery of high quality right:
improvement tool to over 1,000 GP practices.
care. As a healthcare system, we need to decide
whether we provide services based on • Stabilising the condition to get patients back to
LUNG living their lives
organisational structure or on meeting patients • Supporting patients to live their lives through
needs. monitoring and review
• Timely intervention to the appropriate service
when things go wrong
Further information can be found at: STROKE • Providing choice and support towards the
www.improvement.nhs.uk/ltc end of life
NHS Improvement There are areas of good practice and some evidence of
integrated service provision though this is sporadic
NHS Improvement Effective pathways for across the country. Taking a pathway approach to care
delivery, NHS Improvement has focused on four key
3rd Floor | St John’s House | East Street | Leicester | LE1 6NB
Telephone: 0116 222 5184 | Fax: 0116 222 5101 long term conditions areas where patients want us to get it right regardless of
the disease. The examples within the areas of focus
highlight specific specialty approaches but they have
www.improvement.nhs.uk wider applicability regardless of the disease or for
patients with one or more conditions. There is a
challenge for specialist services to reduce the variation in
their approach to those with more than one condition.
Delivering tomorrow’s There is also the question of meeting patient needs
seven days a week rather than the five day service
improvement agenda widely provided across the country which results in
delays to treatment and a flurry of activity and decision
for the NHS making on a Monday morning. Further information on
seven day working can be found at:
www.improvement.nhs.uk/7dayworking

2. STABILISING THE CONDITION TO ASSISTING PATIENTS TO TIMELY INTERVENTION TO THE PROVIDING CHOICE AND
GET PATIENTS BACK TO LIVING LIVE THEIR LIVES WITH APPROPRIATE SERVICE WHEN SUPPORT TOWARDS THE END
THEIR LIVES SUPPORT PROVIDED THROUGH THINGS GO WRONG OF LIFE
MONITORING AND REVIEW
Everyone would aspire to diagnosing and treating Care coordination is a function that should ensure that care Patients often say that it is a struggle to get timely access Many people with a long term condition(s) will
conditions earlier so that the impact of the condition on and support is joined up, safe, effective, consistent, and when things go wrong. This may be because they did not deteriorate over time, their periods of wellness will be of
quality of life can be minimised and individuals can get improves outcomes and quality of life. Care may be know what to look for, or they were unable to access the a shorter duration and there may be more frequent
back to living their lives. To this end, there need to be coordinated by the patient, their carer, or a member of the services when they needed them. The service needs to episodes of things going wrong. It may be that the
systems in place that address awareness of the signs of professional team. Giving or receiving peer support is an respond in a timely manner and have information that can patient moves from managing themselves to their
conditions developing, rapid access clinics in hospital or the important part of dealing with different conditions. support the rapid resolution of the problem. Regardless of care and support being increasingly managed by the
community, and use of effective tests and diagnostic tools Monitoring through tests to pick up problems or reviews to the trigger(s) that signals that things may have gone wrong, multidisciplinary team, as their condition
to get the right diagnosis, first time. Treatment should be ensure patients’ needs are being met are important timely access to an appropriate professional is required to deteriorates.
evidence based and optimised to take into account the components of the package to support self management. ensure intervention is right first time.
individual and any other conditions they may have to
ensure greatest efficacy with fewest side effects, which
could impact on co-existing disease or the individual’s quality
Advance care planning management
of life. Joint partnership to review care needs Shared care approach
NHS Brent Primary Care Trust
South Tees Hospitals NHS Foundation Trust Western Sussex Hospitals NHS Trust, Norfolk
In Brent, an end of life care pathway has been
Stroke care coordinators from health and social care and Norwich University Hospitals NHS
created for end stage heart failure patients, helping
within South Tees have developed joint partnership Foundation Trust
Moving On programme to reduce the number of A&E attendances and the
working to review and monitor the care needs of Teams at Western Sussex Hospitals NHS Trust and
Ipswich Hospital NHS Trust number of patients who had no choice but to die in
stroke survivors in care home settings at around six Norfolk and Norwich University Hospital both
Following a holistic needs assessment at the end of hospital. This has been brought about through
months to ensure an equitable service provision to established regular multi-disciplinary meetings across
treatment, cancer patients are encouraged to improved communications between the hospital and
all stroke survivors. Joint partnership working primary, secondary and community care
attend a four week ‘Moving On’ programme (two community through partnership working that has
reduces the need for the individual to repeat organisations to discuss and proactively manage
hours per week) held in the Cancer Information provided improved choice for patients. The revised
personal information, provides a more holistic patients with COPD who were frequently admitted
Centre covering topics such as symptom pathway includes a ‘trigger tool’ to recognise that
assessment of care needs and supports the carers to hospital. This was a small group of patients but
management, goal setting, diet and physical the patient is probably approaching end of life, the
with more consistent information. Joint review often they accounted for a high proportion of
activity, fatigue, relationship and sexual issues, ‘patient and carer assessment tool’ providing
reduces the duplication of information for the admissions to hospital. By taking a proactive, shared
returning to work, financial issues, worries and assessment of the patient symptoms and carer needs
patient and carer and enables the patient to be care approach to these patients the community staff,
fears. A care plan based on individual needs is to aid appropriate referral to specialist palliative care
reviewed in their own environment reducing the risk who were often not respiratory specialists, felt better
developed and any further support identified and support and the ‘Red Folder’ in patients’ homes that
of stress or discomfort when travelling to a clinic able to support the patients to remain in their
arranged if required. As well as providing education contains advance care planning management,
appointment. homes and prevent avoidable admissions.
and support the programme offers peer support at accessible by district nurses, out of hours and
a time when many patients feel isolated and alone ambulance services.
following completion of treatment.
Remote monitoring Reducing hospital admissions
North Bristol NHS Trust University Hospital of North Staffordshire NHS
Access to the right care and information
In North Bristol NHS Trust they have recently Trust, North Staffordshire PCT & Stoke on Trent PCT
Web-based rehabilitation Solihull Community Care NHS Trust
introduced a remote monitoring solution for Current practice for end stage heart failure patients is
University Hospitals of Leicester NHS Trust Predicting when someone with COPD may be within
prostate cancer patients that separates the to hospitalise those who are symptomatic for
University Hospitals of Leicester have created a six to twelve months of end of life can be very
surveillance test from the need for an outpatient intravenous or subcutaneous diuretics delivered
unique web-based Cardiac Rehabilitation difficult due to the disease trajectory. However
clinic. Patients requiring routine monitoring of their predominantly by generalists with little specialist
programme for suitable patients. This provides a primary care clinicians can access a range of
PSA get a letter reminding them to have their test knowledge of heart failure or palliative care. However,
different approach to the delivery of rehabilitation. indicators which are designed to assist with this
done. The result of the test is reviewed on the a community based project in Stoke for subcutaneous
This has the potential to allow increased numbers challenge, and can help identify patients so that
monitoring system by the urology nurse specialist diuretics to HF patients has helped avoid hospital
of patients to have more convenient, quick access they can access the right care, appropriate
and results are sent to the patient and GP with any admissions, increase the input of the specialist multi-
to a rehabilitation package that can be undertaken information and be able to plan ahead. Solihull
further instructions or actions that may be required. disciplinary as well as improve choice for patients.
more conveniently at their own pace through the Community Care NHS Trust identified COPD patients
Patients who do not have their test can be identified
use of technology. Early indications suggest that in 12 of their GP practices who were nearing the
and followed up, reducing the risk of patients falling This community service is a safe and acceptable
this style of rehabilitation may appeal to those end of life and were able to offer them access to
through the net. Patients are positive about this alternative to hospitalisation for intravenous diuretics
patients who wish to return to work/normal activity palliative medicines and support as well as Advance
system as it means they do not need to go to and the patients (and future potential users of this
more quickly, and who may have previously not Care Planning, comprising advance decisions,
hospital for an appointment but know that their service) and their carers welcome this intervention. The
taken up a rehabilitation package because of this. choosing preferred place for care and capturing
specialist team is keeping watch from a distance. intervention in 13 patients reduced hospitalisations by
views on resuscitation.
27 and saved a total of 344 bed days.