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09 - Management of Long Term Conditions

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09 - Management of Long Term Conditions ...

     MANAGEMENT OF LONG TERM CONDITIONS ITEM 9

     Decision Discussion Information

IMPACT ON STRATEGIC DIRECTION: The aim of the report is to guide the development and

    organisation of services for patients with long term conditions and to inform the Board of the

    national performance targets that must be achieved in relation to this patient group.

FINANCIAL IMPACT: Service redesign in order to produce better outcomes, slow disease

    progression, reduce disability, ensure better management of the sudden deteriorations often

    associated with long term conditions will result in improved quality of life for patients and

    reduced need for admission to hospital.

IMPACT UPON SERVICE USERS: Supporting patients to manage their own conditions will

    empower patients, improve their experience of services and improve their health outcomes.

IMPACT UPON STAFF: The report and decisions made will inform staff of the strategic

    direction to be taken within Hillingdon to manage patients with Long Term Conditions. New roles, e.g. Community Matrons and new responses to service provision will integrate care

    delivery.

    IMPACT UPON INTERNAL AND EXTERNAL PARTNERS: The delivery of the strategy requires work across cultural and organisational boundaries to develop integrated, patient

    centred services which will transform care for patients with long term conditions.

    IMPACT UPON EQUITY: Patients will be provided with a service based on need.

IMPACT UPON PCT OBJECTIVES: The paper demonstrates the strategic direction required

    to support the Local Strategic Partnership priorities to

    1. Improve the health and well-being of the population

    2. Support Hillingdon residents with long term conditions

    3. ensure fair and prompt access to care in Hillingdon

    4. Promote quality of life ,independence and choice

    As well as supporting the four principles identified in Hillingdon's Vision for Health 1. People should receive health care as close to home as possible 2. people should receive the appropriate treatment in the appropriate place at the appropriate

    time

    3. Allow patients to take control of their own long term condition - education and support must be available for them to be "expert patients".

ANY OTHER CRITICAL INFORMATION: N/A

    Hillingdon Primary Care Trust Board (PART ONE PUBLIC MEETING) Date: 25 January 2005 Page No 1

     MANAGEMENT OF LONG TERM CONDITIONS ITEM 9

    Contact Name: Esme Young

     Contact Tel No: 01895 452056

SUMMARY

    The need for effective management of chronic long term conditions is a growing priority for

    the NHS and has the potential to have a great impact on the effectiveness and efficiency of

    the use of resources across health economies. Hillingdon PCT together with the health and

    social care economy needs to develop a systematic approach to providing care for people

    with long term conditions.

RECOMMENDATIONS

Board is requested to:

1. AGREE TO THE ESTABLISHMENT OF A POST FOR A NETWORK DIRECTOR

    FOR LONG TERM CONDITIONS.

2. AGREE TO THE PRIORITSATION OF THE DEVELOPMENT OF A SYSTEM OF

    PROACTIVE CASE MANAGEMENT INCLUDING THE DEVELOPMENT OF THE

    ROLE OF COMMUNITY MATRONS.

3. AGREE TO THE PCT USING DATA SOURCES AVAILABLE (QMAS, CLEARNET)

    TO IDENTIFY THE NUMBER OF PEOPLE IN HILLINGDON LIVING WITH LONG

    TERM CONDITIONS.

4. REQUEST REPORTS ON THE PROGRESS ON MANAGING LONG TERM

    CONDITIONS.

5. TO SUPPORT THE DEVELOPMENT OF THE EXPERT PATIENT PROGRAMME

6. TO AGREE TARGETS FOR THE ACHIEVEMENT OF THE PATIENT SERVICE

    AGREEMENTS.

INFORMATION

1. Context

    1.1 Aim To develop an overall structured and systematic approach to providing care for people with Long Term Conditions, with informed patients interacting in

    partnership with a proactive health care team.

The need for effective management of chronic long term conditions is a growing priority for

    the NHS and has the potential to have a great impact on the effectiveness and efficiency of

    the use of resources across health economies. Both the „NHS Improvement Plan „and the

    planning framework ‟National Standards, Local Action‟ highlight the management of Long

    Term Conditions as a key priority over the next four years.

    Hillingdon Primary Care Trust Board (PART ONE PUBLIC MEETING)

    Date: 25 January 2005 Page No 2

The challenge is to work across boundaries both cultural and organisational - and develop

    the integrated, patient centred services which will transform care for patients with long term

    conditions.

    1.2 National statistics

National data indicates

    ? 60% adults in England report a chronic health problem

    ? 17.5 million people may be living with a chronic disease

    ? By 2003 the incidence of chronic disease in people 65 years plus will have doubled

    ? 80% GP consultations relate to chronic disease

    ? 5% of those admitted as inpatients account for 42% of all inpatient days

    ? 10% of those admitted as inpatients account for 55% of all inpatient days

It is estimated that an individual PCT will have somewhere in the region of 825 frequent

    flyers/very high intensity users ( patients frequently using health services and having multiple

    hospital admissions) and an average sized General Practice will have approximately 25

    patients. Of these only 1:4 patients will be known to the District Nursing Service and 1:3 will

    be known to Social services.

    1.3 Drivers for Change

There are a number of drivers for change in the system. They include political will, changes

    in Primary Care contracting the nGMS contract, Pharmacy contract, Practice Led

    Commissioning, National Service Frameworks, Modernisation agenda Agenda for Change,

    Liberating the Talents, Quality and Outcomes Framework, Expert Patient Programme,

    development of Community Matrons, national and local demographics. Another powerful

    driver for change is the following Public service agreement targets:-

To improve health outcomes for people with long term conditions by offering a

    personalised health care plan for vulnerable people most at risk.

To reduce emergency bed days by 5% by 2008, through improved care in primary care

    and community settings for people with long term conditions.

    1.4 Policy Development

Alternative models of care have been piloted in the UK during the last two years. A policy

    document Supporting People with Long Term Conditions was published in January 2005

    with supporting documents due Spring 2005 and a National Service Framework for Long

    Term Neurological conditions is due to be published in late 2005. The Department of Health

    has facilitated evaluation of the following models:

Castlefields Health Centre

    ? 15% reduction in unplanned admissions

    ? 31% reduction in hospital length of stay

    ? Total hospital bed days fell by 41%

    ? Significant savings

    ? Better patient and carer experience

    ? Improved integration of services

    Hillingdon Primary Care Trust Board (PART ONE