Long Term Conditions Helen Walley

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Long Term ConditionsHelen Walley

• Strategy Development Workshop 7th January 2005

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Supporting People with Long Term Conditions
Supporting People with Long-term Conditions

• An NHS Social Care Model to support local
  innovation and integration
• Published 5th January 2005

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Current National and Local Requirements

• The problem
• Seventeen and a half million people in this
  country report a long term condition (such as
  diabetes, asthma or arthritis).
• 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.

National Local requirements
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Current National and Local Requirements

• 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.
• Only about 50 of medicines are taken as
  prescribed.

National Local requirements
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Current National and Local Requirements
National Local requirements

• The strategic aim
• To embed into local health and social care
  communities an effective, systematic approach to
  the care and management of patients with a long
  term condition.
• To reduce the reliance on secondary care services
  and increase the provision of care in a primary,
  community or home environment.

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Current National and Local Requirements

• Patients with long term conditions need
  high-quality care personalised to meet their
  individual requirements.
• The Public Health White Paper Choosing Health
  underpins the entire long term condition
  approach. This will build on the publics
  growing desire for a healthier future by ensuring
  that the self care support is in place for people
  particularly those in disadvantaged groups and
  areas to make healthier choices about diet,
  physical activity and lifestyle.

National Local requirements
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Vision

• PSA National Target -
• To improve health outcomes for people with
  long-term conditions by offering a personalised
  care plan for vulnerable people most at risk
• and to reduce emergency bed days by 5 by 2008
  (from the expected 2003/04 baseline), through
  improved care in primary care and community
  settings for people with long-term conditions.

Vision
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Number of multiple admissions, 2002/3 all
diagnoses (long term and acute)
Vision
Number of people divide by around 2.5
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Multiple admissions, Rate per 1000, 2002/3 all
diagnoses (long term and acute)
Vision
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Selected long term conditions-
Number of multiple admissions, 2002/3, for SW
London

• COPD 966
• Heart failure 742
• Angina 671
• Asthma 365
• Sickle cell 338
• Epilepsy 293
• Chronic ischaemic heart disease 247
• Chronic renal failure 216
• Diabetes (types I and II) 210
• Hypertension 26

Vision
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Progress so far

• Established Steering Group
• Chair Helen Walley
• Membership
• St Georges Hospital
• Sutton Merton PCT
• Pharmacist
• Lambeth PCT
• Strategic Health Authority
• Mental Health Trust
• Chelsea Westminster NHS Trust
• Workforce Development Confederation
• London Ambulance Service

Progress so far
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Progress so far

• Stakeholder Group

Progress so far
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Progress so far

• COPD
• Diabetes
• Older People with complex needs
• Heart Failure
• IT

Progress so far
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Progress so far

• Commissioned Data Collection and Project
  Management

Progress so far
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Short and Medium Term Objectives

• To establish function process
• To gather the information about actual usage of
  services both secondary and primary care
• To identify best practice
• To disseminate, implement and monitor best
  practice guides
• To agree outcome measures including patient
  satisfaction

Short Medium Aims
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What we need from the enabling strands

• IT
• Changes to workforce i.e. community matrons
  (expert patient programme)

Enablers
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Group Work 40 Minute Discussion

• Do you understand what has been said?
• Would you like to see anything else included in
  a) the vision b) the work of the group?
• Is this special enough for Wandsworth
• What links can you see with other parts of the
  strategy?
• Are there any other comments you want to make?