THE BROAD PICTURERECENT DEVELOPMENTS IN LONG-TERM

CONDITION MANAGEMENT

DR AILEEN KEEL

DEPUTY CHIEF MEDICAL OFFICER

May 2007

THE BROAD PICTURERECENT DEVELOPMENTS IN LONG-TERM CONDITION MANAGEMENT

• Strategic Direction• CMO Workstream• Long Term Conditions Alliance Scotland• Self Care• CHP Toolkit• SPARRA/Integrated Care• Managed Clinical Networks• Related Policies

THE BROAD PICTURERECENT DEVELOPMENTS IN LONG-TERM CONDITION MANAGEMENT

Strategic Direction (1)Key to managing long-term conditions (Kerr Report)

• Multidisciplinary team holistic care• Patient involvement self care• 1° care coordinated care in least intensive setting• hospital visits/admissions• Integrate 1°/2° care and health/social care• Population approach 1° care register of LTC patients• Use of IT/evidence based protocols/better medicines management• Use of voluntary sector/support for family carers

• Tackling Health Inequalities• Shifting the Balance of Care• Long Term Conditions• Diagnostics• Planned Care• Unscheduled Care• eHealth• Rural Health Care• Mental Health • Child and Maternal Health• Tertiary Paediatric Care• Neurosciences

THE BROAD PICTURE RECENT DEVELOPMENTS IN LONG-TERM CONDITION MANAGEMENT

Strategic Direction (2)

THE BROAD PICTURE RECENT DEVELOPMENTS IN LONG-TERM CONDITION MANAGEMENT

Strategic Direction (3)

Current Model of Care• Geared towards acute

conditions• Hospital centred• Doctor dependent• Episodic care• Disjointed care• Reactive care• Patient as passive recipient• Self care infrequent• Carers undervalued• Low tech

Evolving Model of Care• Geared towards long-term

conditions• Embedded in communities• Team based• Continuous care• Integrated care• Preventive care• Patient as partner• Self care encouraged and facilitated• Carers supported as partners• High Tech

THE BROAD PICTURERECENT DEVELOPMENTS IN LONG-TERM CONDITION MANAGEMENT

Strategic Direction (4) – Systematic Approach

• More effective matching of patient’s needs to level of response• Holistic approach to patient’s needs when they have more than one condition• Use of IT to deliver joined up care• Use the skills of the whole clinical team more effectively• Develop systematic contact and support for patient self care• Reduce emergency admissions• Ensure consistency of approach and dissemination of best practice

THE BROAD PICTURE RECENT DEVELOPMENTS IN LONG-TERM CONDITION MANAGEMENT

Strategic Direction (5)

Tier 4

Care Management

Tier 3

Disease Management

Tier 2Supportedself care

Tier 1 HealthImprovement

Health Improvement/AnticipatoryCare

High complexity,Vulnerability 3-5% of LTC Population

High Risk Cases

15%-20% of LTC

70-80% of long Term conditionpopulation

100% of the

whole

population

THE BROAD PICTURERECENT DEVELOPMENTS IN LONG-TERM CONDITION MANAGEMENT

CMO Workstream (1)

National Strategy (Delivering for Health):

• Steering Group: NHS and Long-Term Conditions Alliance Scotland (LTCAS)

• Open Space events and report “People’s experiences of being with or caring for someone with long-term conditions must be central to how services are designed and delivered.”

THE BROAD PICTURE RECENT DEVELOPMENTS IN LONG-TERM CONDITION MANAGEMENT

CMO Workstream (2)

THE BROAD PICTURERECENT DEVELOPMENTS IN LONG-TERM CONDITION MANAGEMENT

Long Term Conditions Alliance Scotland • Established 2006

• A national voice to ensure the interests and needs of people living with long term conditions are heard and addressed

• 4 overarching aims:

• Influencing and campaigning• Supporting and improving practice• Supporting the voluntary and community long term condition sector• Tackling health inequalities

THE BROAD PICTURERECENT DEVELOPMENTS IN LONG-TERM CONDITION MANAGEMENT

Self Care (1)

• Allows people living with long term conditions to achieve and maintain optimum wellbeing

• LTCAS ‘Gaun Yersel’ conference November 2006• Supported Self-Care in Cancer Programme

• LTCAS Sub-Group

• Departmental secondee

THE BROAD PICTURE RECENT DEVELOPMENTS IN LONG-TERM CONDITION MANAGEMENT

Self Care (2) (LTCAS report)

Self-management programmes

should include:• Relevant information• Information about

benefits of diet and exercise

• Coping techniques and pain management strategies

• Peer support, to make it easier to accept the ‘gaun yersel’ message

Outcomes of self-management:• Increased effectiveness of

medical treatment• Helps people manage their

condition properly• Improves health and reduces

pain, fatigue and depression• More efficient use of NHS

resources, through e.g. reduction in number of GP visits

• Improvement in self-confidence levels

THE BROAD PICTURERECENT DEVELOPMENTS IN LONG-TERM CONDITION MANAGEMENT

CHP Toolkit

HDL(2007)10

• Mandatory for all 41 CH(C)Ps

• Standard 3: Service Design and Multi-disciplinary/multi-agency working

• Criterion 3.3: “CHP has range of services including …… palliative care (taking account of Gold Standards Framework Scotland) ……”

• Action Plans

THE BROAD PICTURERECENT DEVELOPMENTS IN LONG-TERM CONDITION MANAGEMENT

SPARRA/Integrated Care

• Scottish Patients at Risk of Readmission and Admission

• Risk Reduction Algorithm: identifies patients at high risk of unscheduled hospital admission

• Assumes intensive case management available to those patients

• Need to systematise (Workshop 22 May)

THE BROAD PICTURERECENT DEVELOPMENTS IN LONG-TERM CONDITION MANAGEMENT

Managed Clinical Networks (1)

• Acute Services Review 1998

• “MCNs are linked groups of health professionals and organisations from primary, secondary and tertiary care, working in a co-ordinated manner, uncontained by existing professional boundaries, to ensure equitable provision of high quality, clinically effective services throughout Scotland.”

• NHS MEL(1999)10: 9 February 1999

• NHS HDL(2002)69: 18 September 2002

THE BROAD PICTURERECENT DEVELOPMENTS IN LONG-TERM CONDITION MANAGEMENT

Managed Clinical Networks (2)

• HDL(2007)21: Strengthening the Role of MCNs

• Key tool to deliver further transformational change through:

• Improving service quality and performance management• Acting as planning fora for disease areas or topics

• Examples: CHD, stroke, diabetes, MCNs; respiratory MCNs; palliative care MCNs; chronic pain MCN in Greater Glasgow and Clyde

• Managed Care Networks

THE BROAD PICTURERECENT DEVELOPMENTS IN LONG-TERM CONDITION MANAGEMENT

Related Policies

• Joint Futures: single shared assessment• Carers’ strategy• ‘Changing Lives’: social work review• Visible, Accessible and Integrated Care: review of community nursing• ‘Delivering for Mental Health’• Rehabilitation Framework• Joined up Thinking, Joined up Care

THE BROAD PICTURERECENT DEVELOPMENTS IN LONG-TERM CONDITION MANAGEMENT

Summary (1) – Strategy for LTCs

Why?

• Ageing Population

• Number of people with multiple LTCs complex

• Disadvantaged communities more LTCs

• Small number of people with LTCs disproportionate health care deployment

(eg ~ 80% GP consultations)

THE BROAD PICTURERECENT DEVELOPMENTS IN LONG-TERM CONDITION MANAGEMENT

Summary (2) – Strategy for LTCs

How?

• Building on what has gone before

- MCNs - CHPs - Kerr - Delivering for Health

• Strengthening and extending 1° care

• Anticipatory care for vulnerable cases

• Support for self care