LTC year of care commissioning early implementer sites workshop held on 1 December 2014. Featuring Dr Martin McShane, Rob Meaker and Renata Drinkwater.

1. WELCOME
LTC Year of Care Commissioning
Early Implementer Sites Workshop
1 December 2014

2. Plan for the day:

4. Events
Date & Time Event & Time Location
8 December 2014
2 – 4pm
EIS Project Leads Forum WebEx
19 January 2015
2 – 4pm
EIS Project Leads Forum WebEx
2 February 2015
10.30am – 3.30pm
LTC Year of Care EIS Workshop Workshop in London
16 March 2015
2 – 4pm
EIS Project Leads Forum WebEx

6. LTC Lunch & Learn Series ….coming soon…
To register email LTC@nhsiq.nhs.uk
Date Webinar Hosted by Bev Matthews &
3 December 2014
1 – 2pm
Population level commissioning
for the future
Dr Abraham George
Kent County Council
7 January 2015
1 – 2pm
Self Management Support
Return on Investment
Renata Drinkwater
Chief Executive & Trustee Self
Management UK
21 January 2015
1 – 2pm
Commissioning for Outcomes Bob Ricketts CBE
Director of Commissioning Support
Services & Market Development,
NHS England
4 February 2015
1 – 2pm
Accountable Care Organisations
in the USA & England testing,
evaluating and learning what
works
Dr Rachael Addicot
Senior Research Fellow, Kings Fund

7. www.england.nhs.uk
Chronic
conditions – a
new approach
Dr Martin McShane
Director – Domain2
Enhancing the quality of life for
people with long term
conditions

8. 5YFV:
Demand for care is rapidly growing
We are facing a rising burden of avoidable illness
across England from unhealthy lifestyles:
•1 in 5 adults still smoke
•1/3 of people drink too much alcohol
•More than 6/10 men and 5/10 women are
overweight or obese
Furthermore:
•70% of the NHS budget is now spent on long term
conditions
•People’s expectations are also changing
www.england.nhs.uk
4

9. 5YFV:
There are new opportunities
New technologies and treatments
•Improving our ability to predict, diagnose and treat disease
•Keeping people alive longer
•But resulting in more people living with long term
conditions
New ways to deliver care
•Dissolving traditional boundaries in how care is delivered
•Improving the coordination of care around patients
•Improving outcomes and quality
…but the financial challenge remains, with the gap in 2020/21
previously projected at £30bn by NHS England, Monitor and
independent think-tanks
www.england.nhs.uk

10. The new ‘epidemic’?
Number of Conditions1 % self reporting
www.england.nhs.uk
1 30%
2 13%
3+ 10%
The 15 million people in England with long term
conditions have the greatest healthcare needs of the
population (50% of all GP appointments and 70% of all
bed days) and their treatment and care absorbs 70% of
NHS and social care budgets in England
1. The percentage of people aged 18 and over self-reporting experiencing long-term conditions in the GP Patient Survey

11. Multimorbidity is very common
Percentage with more than one of 17 major chronic conditions, by age and sex
50
45
40
35
30
25
%
20
15
10
5
0
18-24 25-34 35-44 45-54 55-64 65-74 75-84 85+
Overall:
Age-group
16% of population have multimorbidity (based on 17 QOF diseases)
57% have multimorbidity (based on 115 ACG diseases)
MALE
FEMALE
Salisbury et al, BJGP, 2011

12. Impact on health care system
Annual consultation rate by age and multimorbidity status
14
12
10
8
6
4
2
0
Salisbury et al, BJGP 2011
18-24 25-34 35-44 45-54 55-64 65-74 75-84 85+
annual consultation rate
multimorbid not multimorbid
People with multimorbidity account for 16% of the population
but account for 33% of all consultations

13. Bridging the gap: Financial Context
www.england.nhs.uk
7

14. www.england.nhs.uk

15. Financial and population ‘gearing’
www.england.nhs.uk
12/12/
2014
Primary
£200
(6.5k)
Community &
MH
£500
Specialist
£300
Acute
£1000
(330k)
Social Care
Public Health

16. 1990
2014
CARE
GAP
GP Specialist
Specialist
Activity
Complexity
www.england.nhs.uk 10

17. Care Context
There are three levels of personalised care and support needed:
• People who are without an LTC but who need proactive advice
as they are at risk, e.g. of CVD or diabetes
• Those with single or synergistic conditions for whom
standardised care through evidence based practice is generally
well established and national incentives, guidance and
processes support a focus for this group, although there are still
improvements to make.
• However, the group yet for the NHS (and partners) to create the
right system for are those with multiple conditions and the rising
demand for the prevention and management of multi-morbidity
through an individualised approach to care.
www.england.nhs.uk

18. Levels of Care - Stratification
Complex
Simple
No LTCs
Stratifying risk Stratifying Care Design Stratifying care delivery
www.england.nhs.uk
12
Multiple
Single/
Synergistic
Condition(s)
Prevention
Individualised
Standardised
Proactive advice

19. Specialist Functions….for a
population
www.england.nhs.uk
Building
generalist
capability and
quality
Support
for
Generalist
Specialist
Services

20. 5YFV:
Developing new care models
www.england.nhs.uk
12/12/
2014
•We need to take decisive steps to transition towards better care
models
•There is wide consensus that new care models need to:
 Manage systems (networks of care), not just organisations
 Deliver more care out of hospital
 Integrate services around the patient
 Learn faster, from the best examples around the world
 Evaluate success of new models to ensure value for
money

21. Multispecialty Community Providers
What they are
• Greater scale and scope of
services that dissolve traditional
boundaries between primary and
secondary care
• Targeted services for registered
patients with complex ongoing
needs (e.g. the frail elderly or
those with chronic conditions)
• Expanded primary care leadership
and new ways of offering care
• Making the most of digital
technologies, new skills and roles
• Greater convenience for patients
www.england.nhs.uk
How they could work
• Larger GP practices could bring in
a wider range of skills – including
hospital consultants, nurses and
therapists, employed or as
partners
• Shifting outpatient consultations
and ambulatory care out of
hospital
• Potential to own or run local
community hospitals
• Delegated capitated budgets –
including for health and social
care
• By addressing the barriers to
change, enabling access to
funding and maximising use of
technology
12/12/2014

22. Primary and Acute Care Systems
What they are
• A new way of ‘vertically’
integrating services
• Single organisations providing
NHS list-based GP and hospital
services, together with mental
health and community care
services
• In certain circumstances, an
opportunity for hospitals to open
their own GP surgeries with
registered lists
• Could be combined with
‘horizontal’ integration of social
and care
www.england.nhs.uk
How they could work
• Increased flexibility for Foundation
Trusts to utilise their surpluses
and investment to kick-start the
expansion of primary care
• Contractual changes to enable
hospitals to provide primary care
services in some circumstances
• At their most radical they could
take accountability for all health
needs for a register list – similar to
Accountable Care Organisations

23. w1w2w/1.e2ng/l2an0d1.n4hs.uk

24. w1w2w/1.e2ng/l2an0d1.n4hs.uk

25. www.england.nhs.uk

26. Population system approach
LTC Framework:
• Empowered patient and carers
• Professional collaboration
• Best Practice (clinical and organisational)
• Commissioning
www.england.nhs.uk

27. www.england.nhs.uk
The House of Care
Organisational and clinical
supporting processes
Engaged,
informed
individuals
and carers
Health and
care
professionals
committed to
partnership
working
Person-centred
coordinated
care
Commissioning

28. LTC Framework
The table below sets out some of the key components needed to deliver the central
aim for LTC Framework - Person Centred Coordinated Care
www.england.nhs.uk
22
Organisational &
Clinical
Processes
Informed and
engaged patients
and carers
Health & Care
Professionals
committed to
partnership
working
Commissioning
• Information and
technology
• Case finding & risk
stratification
• Care Planning
• Safety and
Experience
• Guidelines,
evidence and
national audits
• Care Delivery
• Self Management
• Information and
Technology
• Group and Peer
Support
• Care Planning
• Policies for carers
• Voluntary sector
patient & carer
support
• HSC Integration
• Multi Disciplinary
Teams
• Culture
• Workforce
• Technology
• Care Co-ordination
• Care Planning
• Needs
Assessment and
Planning
• Joint
Commissioning
• Metrics and
Evaluation
• Service User and
Public Involvement
• Contracting and
Procurement
• Care Planning
• Tools and Levers

29. Goal
My
goals/outcomes
Emergencies
www.england.nhs.uk
Person centred
coordinated care
“My care is planned with people who
work together to understand me and my
carer(s), put me in control, co-ordinate
and deliver services to achieve my best
outcomes”
Communication
Information
Care planning Decision-making
Transitions
23

30. http://www.england.nhs.uk/house-of-care/
Resources
1.Toolkit
2.Dashboard
3.Infographic
4.Improvement programme
www.england.nhs.uk

31. The soft stuff…is the hard stuff
Individual
behaviours
www.england.nhs.uk
25
Mindsets
and beliefs
Values
SOURCE: Scott Keller and Colin Price, ‘Performance and Health: An evidence-based approach to transforming
your organisation’, 2010.
Needs
(met or unmet)

32. ICare
Community
Care
The Future: 2014-2019
Social Care
Primary
Care
University/
Specialist
Facilities
General
Hospital
www.england.nhs.uk 26

33. www.england.nhs.uk NHS Expo Seminar
Domain 2
27

34. Rob Meaker
Director of Innovation, Barking,
Havering and Redbridge CCGs

35. Complex Primary Care Practice in East London

36. East Of
England
Cluster 3
Cluster 1
Hospital LAS Station
Cluster 1
Central
London
Cluster 2
Cluster 4
Cluster5
Cluster4
Cluster 1
Cluster2
Cluster6
Cluster 2
Cluster 3
Cluster 4
Cluster 5
Cluster 6
Walk In
Centre
Total Population 759,285
BHR
Dashboard
£55m
Havering
Non elective admissions
£8.8m
A&E attendances
Barking
£36.5m
Non elective admissions
£7.6m
A&E attendances
Redbridge
£50m
non elective admissions
£7.6m
A&E attendances
Overview of BHR CCGs’ Health Economy

37. BHR CCGs’ Development Timeline
2008 – Polysystems & Person Centred Care
2009 – Risk Stratification
2010 – Integrated data
2011 – LTC management, & The Year of Care
2012 – Integrated Case Management
2013 – Rapid Response & Community Treatment Teams
2014– Complex Primary Care Practice
Health 1000 Ltd, the Complex Primary Care Practice, is a Primary Social and Acute Care
System located in King George Hospital, Ilford

38. How BHR CCGs are Implementing a Primary, Social and Acute Care System
Health1000 is a new primary care
evolved provider organisation
operating a new model of care being
developed as part of the Prime
Minister’s Challenge fund and aligned
to the PACS (Primary and Acute Care
Systems) models set out in the 5 Year
Forward Plan.
The Year of care work provided the
foundation for the service design and
the supporting capitated budget.
The model has been designed in
collaboration with the users it intends
to serve and will be guided by what
people with complex needs want to
achieve from their health and social
care

39. Aligning the PSACS model with existing services.
EoL / CHC
> 5 LTCs
Frail/1-3%/2LTCs
3-6%/1LTC
Comm
Pharmacy
GP
BHRUT
NE
London
FT
Cont.
Heath
Care
Integrated
Urgent &
Emergency
Care Service
111
Urgent
Care
Centres
Voluntary
Sector
Meds Man
Non
Year of
Care
Year of
Care
Social
Care
Federated
Urgent and
Planned
Primary Care
Services
Out of
Hospital
London
Ambulance
Complex
Care model
In the future, a unified urgent primary care service joins patients and clinicians
Complex
Patients
Complex Care Service
Individual
Care
Multidisciplinary
Teams
Patients
Children Elderly or
Full time
mothers or
carers
Retired Unemployed
Working
Adults
Planned GP
Appointment
Online Call2
Practice
Non-Direct
Emergency Triage
Primary Care Prof
Support
Online
Existing urgent care services
Implementing a new model of care, it is essential to align the model with other Key
services.
Unified
point of
access
Urgent Primary Care Appointments
Walk-in
Centres
GP Core
Plus 6-10 pm Weekend
opening
GP core
across BHR primary care
New or significantly enhanced
services
Patients flow through primary
Key care Existing services

40. Complex Care Practice Patient Selection
Complex Care cohort
Row Labels Cohort Hypertension CHD Diabetes Stroke Depression COPD Heart Failure Dementia
LTC 5+ 100 99 96 80 70 80 69 75 36
Scottish modified LTC 4+ 1924 1816 1559 1421 863 793 783 679 303
Grand Total 2024 1915 1655 1501 933 873 852 754 339
211 of the cohort currently receive Integrated case Management Services
The Complex Primary Care Practice intends to register 1000, of the 2024
eligible patients
Eligible cohort, must have 4 diagnosed long term conditions from
Hypertension, CHD, Diabetes, Stroke, Depression, Heart Failure and
Dementia.

41. The trend in adjusted cost for all patient in the complex care cohort by service type
The costs have increased for these patients over the 7 years, presumably as more of the patients in the
cohorts need services and/or patients in the cohorts need greater volumes of services
The greatest cost increases over the period for patients in the cohorts were primary care and
community care. In percentage terms, the cost of acute care has decreased over the period.

42. Activity Cost (£)
2012/13 2013/14 2014/15 2012/13 2013/14 2014/15
Cost and Activity for the selected cohort
Primary Care Contact 42.1 45.2 45.1 1,897 2,032 2,030
Pharmacy 134.8 134.1 135.5 2,373 2,362 2,387
Acute care A&E 1.2 1.2 1.0 137 144 120
Outpatient 5.7 5.5 5.6 602 742 764
Daycase 0.6 0.5 0.3 424 366 217
Elective 0.1 0.1 0.1 286 194 174
NEL short-stay 0.2 0.2 0.2 246 228 166
NEL long-stay 0.5 0.5 0.4 1,568 1,570 1,254
Community care Face-to-Face 6.0 10.2 12.3 1,092 1,884 2,172
Telephone 0.5 0.9 1.1 27 47 54
Combined average cost per patient (£) 8,652 9,569 9,337
Total annual cost of patient cohort (£million) 17.51 19.37 18.90
Average annual number of events and average annual cost per patient in the cohort - all CCGs
The averages hide a great deal of variation. If we take one example, patient's in the cohorts on average visit A&E once
a year but over 50% of patients did not visit A&E at all during 2013/14, and one patient visited 41 times .
Perhaps the most striking feature of the data is that large percentages of patient in the complex care cohorts didn't
require acute inpatient care at all in 2013/14.

43. Commissioning the Service, Who, Where, When
Acute Trust Community
Trust
Health1000
Private
Provider
Voluntary
Sector
GP
Federation

44. PSCAS model for implementation
1. Pre-registration Work up 2. Initial Visit 3. Proactive Care 4. Reactive

45. PSCAS staffing model
ROLE WTE at
start up
Start up Cover provided WTE by
month 3
MD and Geriatrician (50:50
role)
1.0 20 hours direct patient care plus 17.5 hours management
plus on call support as required
1.0
HCS Key workers 5.0 73.5 hours per week 8am to 18.30pm Monday to Sunday.
This is a dual function role covering reception and health
care support and requires two members of staff to be on
duty during 08.00 to 18.30pm Monday to Friday
6.0
GPs 3.0 52 hours per week 08am to 18.30pm Monday to Friday
plus
On call for 5 hours per week Monday to Friday 6.30 to
8pm and 24 hours on Saturday and Sunday from 8am to
8pm
A total of 81 hours per week
3.0
Practice Manager 1.0 37.5 hours per week as required to cover 7 days per week
on rota
0.5
Nurse 1.0 37.5 hours per week during 8am to 6.30pm 0
OT 0.5 18.5 hours per week during 8am to 6.30pm 3.0
Physiotherapist 0.5 18.5 hours per week during 8am to 6.30pm 2.0
Pharmacist 0.5 18 hours per week Monday to Friday as required 1
Community Nurse 0.0 Not applicable 4.0
Mental health Nurse 0 Not applicable 0.5
Social Worker 1.0 Seconded from Local Authority

46. Patient Feedback resulting in design changes
People interviewed about the new
Health1000 service told us:
“We feel helpless trying to get the
best care for our mum.”
“The professionals don’t understand
all of my needs.”
“I just want to be able to go fishing. I
don’t want any more operations or
medication, I just want to be able to
o Fly Fishing again. Why wont
anyone help me achieve this ?
Complex Care Service
Individual
Care
Multidisciplinary
Teams
4+ LTCs
Mental Health
Social Isolation
End of Life Needs Complex
Patients
Care plan
developed
Care Navigator
Care
Navigation
package
New and existing services
(Sectors including Voluntary, Charities,
Private Sector, Social models, Communities,
user developed services etc)
Health
1000
Directory of
Services
Scope of existing services Scope of IPC development
a
Updated Service updated to meet the registered
patient needs

47. Information Governance: LTC Year of
Care Early Implementer Sites
Mark Golledge
Programme Lead – Health and Care Informatics
Local Government Association
1st December 2014

48. Background
• Role funded by Department of Health – employed by Local Government Association;
• Aim is to support work of the Integrated Care Pioneer sites around Informatics – liaising with
Government to help unblock challenges, barriers and encourage sharing, learning and
joined up approaches (previous roles in CSU and before that Local Authority Informatics –
although not directly IG);
• Pioneer Informatics Network – one of four work-streams across the Pioneer programme
(others are provider development; workforce and leadership; pricing and finance led by
Monitor);
• Eight areas of focus for the Pioneers on Informatics – my role is to coordinate amongst all
eight:
1. PSN / N3 Interconnect;
2. Secure Email;
3. IG Toolkit (Health and Local Gov);
4. People Driven Citizen Services;
5. Whole Place Analytics;
6. Access to NHS Number;
7. Integrated Digital Care Records
8. Info Sharing for Commissioning;

49. Information Sharing for Commissioning
• Acting as a link between Integrated Pioneer Sites and DH / HSCIC / NHSE / IG Alliance
given existing challenges – including engagement in IG Forum;
What do we know about where we are?
• Information Sharing doc consulted on over the summer currently being reviewed by DH;
• Various S251 arrangements in place until March 2015 including risk stratification covering
health flows although doesn’t cover social care (unless legal basis);
• Challenges around social care flows;
• Monitor guidance around whole place data linkage (including IG section) & Risk Stratification
work underway;
• Southend application to CAG in Dec – element of consent / fair processing;
• Options available (but pros and cons of these e.g. data quality, re-identification limitations):
consent (“gold standard”), pseudonimisation at source, pseudonimisation on landing,
applying for support under section 5 of S251 regulations (Southend), work through HSCIC
using it’s power to collect (but only flows in, not out);
• Best practice / requirement for informing people what is happening with their data;

50. Information Sharing for Commissioning
What Next?
• DH response to consultation on information sharing – we hope will provide details on end-state
and transition arrangements;
• Southend application for S251 (December) and then clarity on next steps for others with DH
(consideration in light of the above) – sessions over next couple of weeks (will continue to
push Year of Care point);
• Seek resolution of social care flows into HSCIC - consideration in light of the above (but
need to also address flows out);
• Sharing of examples where flows are legally happening – pseudonymisation / consent
(whilst recognising limitations of approaches);
• Continuation on work re. informing clients / patients – again sharing examples of good
practice;
• Continue to flag up specific challenges with us so we can raise with DH / IG Alliance;
……What have we missed?

51. Long Term Conditions Improvement Programme
Your Local House – EI Sites perspective on Lessons
Learnt & Knowledge Capture
Lesley Callow & Jill Lockhart
Delivery Support Manager
Improving health outcomes across England by providing
improvement and change expertise

52. Long Term Conditions House of Care
• The 15 million people in
England with long term
conditions have the greatest
needs of the population
• People living with long term
conditions report that they
require person centred coordinated
care
• The House of Care provides
a framework for this to be
delivered

53. The House of Care in value to
people/patients: The House supports
National Voices ‘I’ statements
My goals/outcomes
All my needs as a person were
assessed and taken into
account.
Communication
I always knew who was the
main person in charge of
my care.
Information
I could see my health and
care records at any time to
check what was going on.
Decision-making
I was as involved in
discussions and decisions
about my care and treatment
Care planning as I wanted to be.
I had regular reviews of my care
and treatment, and of my care
plan.
Emergencies
I had systems in place so that
I could get help at an early
stage to avoid a crisis.
Transitions
When I went to a new
service, they knew who I
was, and about my own
views, preferences and
circumstances.

54. The House of Care in
value to NHS:
£1.2bn:
Avoid ambulatory care
sensitive admissions
though e.g. following
NICE guidelines (1)
£0.8bn:
Reduction of hospital
admissions for common
LTCs through integrated care
esp frailty, comorbid (2)
£0.8-1.2bn:
Reduce use of low value drugs,
devices and elective procedures
using commissioning analytics
and clinician education (3)
£0.2-0.4bn:
Empower people in
supportive self-management
(4)
£1-1.6bn:
Shift activity to cost
effective settings
e.g. pharmacy minor
ailments (5)
£0.4-0.6bn:
Avoidance of drug errors
e.g. through electronic
records/e-prescribing (7)

55. Over to you:
As an Early Implementer team please now:
• Rate you status with regard to implementation
of each component
• Considering each component, please populate
the A3 table with your recommendations for
actions that will need to be taken
25 mins

56. Component Key Messages
Foundation
Left Wall
Right Wall
Roof

57. Making self-management work for people with
long-term conditions
LTC Year of Care: Early Implementer Sites (EIS) workshop
Renata Drinkwater
Chief Executive

58. Agenda
What is self management uk?
What are the evidence based benefits of self-management
to patients?
What do patients say they want in relation to self-management?
Zev Taylor’s self-management story
What are the benefits to clinicians, healthcare
professionals and the wider system?
Discussion

59. self management uk
Formerly the Expert Patients Programme Community
Interest Company, now a registered Charity
Over 12 years’ experience working within/for the NHS
At the forefront of self-management education and training
Facilitated delivery of programmes to 100,000+ patients with
long-term conditions
Also programmes for clinicians/healthcare professionals
Delivered face-to-face or online

60. Benefits of self-management to patients
Increased self-confidence and reassurance
Increased control over own health and wellbeing
Better involvement in shared-decision making about own
health and wellbeing
Reduced time off work
Better symptom management, such as reduction in pain,
anxiety, depression and tiredness
Improved physical symptoms and clinical outcomes in people
with arthritis, asthma, diabetes, hypertension, heart disease,
heart failure, stroke, cancer and other conditions

61. Asking patients what they
want
Our 2013 survey

62. Patients want to help themselves!
43% 38%
62%
Say ‘Having a GP that
understands the difficulties of
living with a long-term condition’
25%
Say ‘Being able to connect with
others living with my condition’
Say ‘Healthcare professionals
treating me as an equal with a say
in my treatment’
Say ‘Getting the right advice to
support me in managing my
condition’

63. but the healthcare system is still reluctant to
help them to help themselves …
How much time elapsed between the first diagnosis of your condition and you
being offered a place on a self management course?
11% 10% 9% 10%
6% 7%
48%
Less then 6
Months
6 - 12
Months
1-2 Years 2-3 Years 3-4 Years 4-5 Years More then
5 Years

64. Asking patients what they
want
Our 2014 survey

65. Self-management does make a difference
The self-management course had a positive impact on my life?
55%
30%
11%
4%
Strongly Agree Agree Disagree Strongly Disagree

66. Self-management boosts patient confidence
37%
18%
35%
6%
4%
Strongly Agree Agree Stayed the same Disagree Strongly
Disagree
The self-management course has improved my confidence?

67. Overwhelming endorsement from participants
Would you recommend a self-management course to your friends or family?
39%
49%
9%
3%
Strongly Agree Agree Disagree Strongly Disagree

68. The tangible impact of self-management
Reduced use of NHS resources
“The course has made a major difference to the way I approach
all health professionals with self-confidence and self-belief. The
number of times I need to visit health professionals has been
reduced massively. Over the last two years my medication has
reduced by about 25%, and I believe this is due to the
knowledge I gained from attending the course.”
Self-confidence wellbeing
“The course makes people more aware of how their
symptoms/condition affect their day-to-day health and
wellbeing. If you have more control over your condition, you
have more choice. You can’t let your condition run your life.”

69. The tangible impact of self-management
Helping people get back into work
“I am now able to spend time with my family, go out with my friends
and socialise, and go away on holidays, which I never thought I would
be able to do. I have also created an opportunity for myself to get back
into work and I am extremely proud of this achievement.”
Supporting healthcare professionals
“The course promotes respect and empathy for doctors and the
pressure they are under. I remember one instance where I was taken
to AE and the triage nurse was amazed at how quickly I was able to
describe my symptoms and tell her about my medication. She told me
she often spent 20 minutes on the patient’s medical history. She said it
would save the NHS a fortune if everyone could do what I did that
night.”

70. Zev Taylor’s Story

71. Benefits to clinicians, healthcare
professionals and the wider system
Percentage savings delivered by self management
programmes [1]
GP visits 2.3% Inpatient visits 50%
Nurse visits 13.8%
Outpatients
visits
6.2%
AE visits 12%
Medication
saved
5.4%
[1] Department of Health (2005). Supporting People with Long-term Conditions: An NHS and social care model to
support local innovation and integration. London: Department of Health

72. Benefits to clinicians, healthcare professionals
and the wider system
New self management uk tool developed for Commissioners to
demonstrate benefits
Based on model originally co-developed with the Department of
Health, now significantly enhanced
Shows financial benefits of delivering our programmes patients
(e.g. Self Management for Life/Expert Patients Programme)
Uses Department of Health/Office for National Statistics figures
and evidence from other key studies
Calculates impact for any Clinical Commissioning Group

73. Typical return on investment
For ever £1 spent: £2.24 is
saved!

74. CCG Case Study - Typical system usage and
medication spend
Statistics for CCG Value
People with a Long-Term Condition 61,539
People Newly Diagnosed (Per year) 4,308
Total GP Visits 300,347
Total Nurse Visits 165,191
Total AE visits 67,941
Total Emergency Admissions 17,015
Total Hospital Admissions 40,004
Total Outpatients Visits 203,576
Total Medication Spend £27,968,172

75. Typical Savings
Population with long-term conditions: 61,539
If training delivered to just 240 patients per
annum
(15 x 7 week programmes)
Potential gross saving due to reduced
healthcare utilisation: £210,000 per annum

76. Typical Return on Investment
Cost Benefit Default Costs
Total Cost of Programme £93,750
Total Practice and Commissioner Savings £210,073
Total Saving over Contract Length £116,323
Saving per Year £116,323
Return on Investment: For every £1 spent: £2.24 is saved
Yes, £2.24 saving per £1.00 spent

77. Benefits to clinicians, healthcare professionals
and the wider system
Finally, we calculate if self management uk
programmes were commissioned across England
for just 10% of people with Long Term Conditions
(c1.57m), there would be:
Gross potential system savings of some £1.38bn
per annum
Net potential savings of some £763m pa

78. Enabling patients

79. Group Discussion
How can we make sure self-management
training is offered to
more patients diagnosed with a long-term
condition at the earliest
opportunity in their care pathway?

80. Thank you
Questions?

81. Renata Drinkwater
Chief Executive
T: 03333 445 840
M: 07500 039 736
renata.drinkwater@selfmanagementuk.org
hello@selfmanagmentuk.org