Long Term Conditions Overview

Tuesday, 22 May 2007

Dr Bill Mutch

LONG TERM CONDITIONS

“THE HEALTH CARE CHALLENGE OF THIS CENTURY”4 Dedicated Editions of B.M.J

78% of all NHS Resource

80% of GP Consultations

60% of Hospital Bed Days

61% of 75-84 One Long Term Condition

22% of 75-84 Two or More Long Term Conditions

Monitoring Poverty and Social Exclusion in Scotland 2004 Joseph Rowntree Foundation

DELIVERING FOR HEALTH

THE CARE PARADIGM SHIFT

CURRENT VIEW

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

RELATED WORKSTREAMS

• The ‘shifting the balance of care’ workstream in Delivering for Health

• Implementation of Changing Lives: Report of the 21st Century Social Work Review, and particular the self assessment tool which local authorities have completed and submitted to the Executive

• National Strategy for the Development of the Social Service Workforce

• The work of the Joint Futures Unit, especially in relation to the single shared assessment and the care management training framework

• Guidance on Care Management

• The Executive’s priorities for supporting carers, as set out in the response to The Future of Unpaid Care in Scotland and guidance on Carer Information Strategies

• Better Outcomes for Older People and the Strategy for a Scotland with an Ageing Population, due to be published in January 2007

• Developing Community Hospitals: A Strategy for Scotland

• Visible, Accessible and Integrated Care, the review of community nursing

• The Rehabilitation Framework

• Delivery of action in The Right Medicine: A Strategy for Pharmaceutical Care in Scotland and the new pharmacy contract

• Improving Frontline Services, A Framework for Supporting Frontline Staff

• Workforce developments such as the Skills for Health Career Framework

• SPARRA (Scottish Patients at Risk of Readmission and Admission), the risk prediction algorithm which ISD published in June 2006, towards which NHS Boards’ own risk prediction tool should be converging

• The work plan on quality improvement in Community and Primary Care Health Services which NHS Quality Improvement Scotland is developing

• Palliative care gold standard

• E-Health Strategy• Audit Scotland review of adults with Long Term Conditions – Baseline Modified from Annex to LTC

Toolkit

NATIONAL STRATEGY FOR CARE OF LONG TERM CONDITIONS

WILL:

Ensure Collaborative Working

Be Led by CMO

Identify Good Practice

Ensure Spread of Good Practice

Share Learning

Encourage Innovation

Identify Areas that Require National Approach &Develop that Support

KEY PRINCIPLES ARE:

Evidence Based Care

Emergent Solutions

Patient / Carer Experience as Driver of Change – Open Space Events

Partnership

CHP LTC TOOLKIT

Organisation of LTC Management

Patient & Carer Information and Supported Self Care

Service Design and Multi-Disciplinary

Multi-agency Working

Interdisciplinary Education & Training

Information and Intelligence

Quality and Delivery

Empowering and enabling patients with long-term conditions to take control of

their own care

Source: Our health, our care, our say, DH

3-5%

15-20%

Public Health, Health Improvement, Health Education

Better outcomes for individuals, their families, carers and communities

Improved access to services

Reduction in the use of unplanned care

Improved concordance with medication

Reduction in the number of professionals involved in the individuals care

Improved choice

Greater continuity of support / care / involvement

More control in the package of care / support provided

Improved and speedier decision making

Empowerment of individual through active participation in the process

Improved partnership working

POTENTIAL BENEFITS OF CASE MANAGEMENT