Long Term Conditions Strategy 2021-2025

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Long Term Conditions Strategy 2021-2025

Supporting people to live well longer

Authors:

Dr Hannah Brayford, Clinical Fellow, ENHCCG

Emily Byway, Project Manager, ENHCCG

Gloria Graham Davidson, Project Support Officer, ENHCCG

Emma Hollingsworth, Programme Manager, ENHCCG

Dr Lucy Kempster, Clinical Fellow, ENHCCG

Dr Sam Williamson, Associate Medical Director, ENHCCG

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CONTENTS PAGE

PAGE SECTION

5 1. Introduction

8 2. Background

14 3. Preventing Long Term Conditions and Co-Morbidities

17 4. Identification, Diagnosis and Staging

18 5. Living with a Long Term Condition – a Proactive Approach

24 6. Managing Multi-morbidities

26 7. Palliative and End of Life Care

27 8. Conclusion

28 Appendix One: Implementation Plan

ACRONYMNS

BAME Black, Asian and Minority Ethnic IMD Index of Multiple Deprivation

BMI Body Mass Index QOF Quality Outcome Framework

BP Blood Pressure LTC Long Term Conditions

CHD Chronic Heart Disease MDT Multi-Disciplinary Team

COPD Chronic Obstructive Pulmonary Disease

NHS National Health Service

DNACPR Do Not Attempt Cardiopulmonary Resuscitation

NICE National Institute for Health and Care Excellence

ENHCCG East and North Hertfordshire Clinical Commissioning Group

ONS Office for National Statistics

GOLD Global Initiative for Obstructive Lung Disease

PHM Population Health Management

GP General Practitioner STP Sustainability and Transformation Partnerships

IAPT Improving Access to Psychological Therapies

SMI Serious Mental Illness

ICP Integrated Care Partnership UK United Kingdom

IDAOPI Income Deprivation Affecting Older People Index

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1. INTRODUCTION

“The increasing prevalence of long term conditions is the biggest

challenge facing the NHS now and in the future”

Miles Ayling, Director of Innovation and Service Improvement

- Department of Health1

The NHS Long Term Plan (2019) identifies the need for the NHS to move to “a new service model in

which patients get more options, better support, and properly joined-up care at the right time in the

optimal care setting”.2

Although both locally and nationally the number of patients with one long term condition has

remained fairly static over the past few years, there is growing concern about the rising number of

people with multiple long term conditions. It is estimated 15% of patients in East and North

Hertfordshire have more than one long term condition and so joined-up care is becoming a greater

priority for patients.

The current health and social care systems are fragmented, often disease focused and care is not

always person-centred in a way that allows individuals to become involved in decisions about their

care. The model of care needs to move away from a disease specific model to a more holistic

approach, taking into account all existing conditions, “risk of” conditions and the wider determinants

of health that can impact on an individual.

The COVID-19 pandemic presented an unprecedented challenge to the NHS. There is now a

proportion of patients that will require long-term care as a result of COVID-19 and a significant

volume of patients with delayed care and unmet needs. However the pandemic has brought a new

focus to patients with long-term conditions and forced care to be delivered in different ways which

can be adopted post pandemic.

The purpose of this strategy is to pull together all recently published guidance and plans relating

to long term conditions to provide the CCG with a strategic direction that identifies how best to

develop a model of care that supports the prevention and management of long term conditions.

1 Department of Health (2012). Report. Long-term conditions compendium of Information: 3rd edition

2 NHS Long Term Plan

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1.1 Aim of the strategy The aim of the strategy is to improve health outcomes, reduce health inequalities, value for money

and to reduce disease progression in long term conditions (LTC) in East and North Hertfordshire;

facilitating more stable baseline over a longer period of time. This is particularly relevant given the

impact of COVID-19 on healthcare services.

The strategy will support the move away from managing LTCs in silo and adopt a more proactive and

holistic approach to care based on individual need. A Population Health Management (PHM)

approach will be adopted throughout this strategy and implementation plan to ensure a needs led

and evidence based approach that appropriately identifies the needs of the population and designs

services around those gaps and requirements

1.2 Strategy Ambitions

Successful delivery and implementation of the strategy recommendations will impact both patients

and the wider healthcare system. The core strategy ambitions are;

Patients (and Carers)

To maintain and improve the quality of care provided to patients

To reduce inequalities in outcomes for key groups within the population

To improve the experience and safety of patients and carers

To increase the level of patient activation for people with a long term condition

To ensure that patients are enabled to manage their condition in their own home or close to

home.

To ensure patients receive coordinated and joined up care.

Healthcare System

To ensure there are appropriate interventions and services that support a patient in

preventing or managing an exacerbation of their condition

To reduce the number of emergency acute admissions and re-admissions (where

appropriate)

To reduce the length of hospital stay for patients with a LTC (where appropriate)

To upskill the healthcare workforce in managing LTCs

To ensure services provide value for money i.e. an optimum combination of cost, quality and

sustainability

To ensure services and initiatives are affordable

1.3 Delivering the strategy To support the robust implementation of the strategy recommendations and to enable system

transformation, a multi-stakeholder and multi-disciplinary approach is required. An East and North

Hertfordshire Integrated Care Partnership (ICP) Board will be established with representation from

all key stakeholders. The Board will be responsible for the delivery of this strategy.

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1.4 Scope of the strategy

The NHS Long Term Plan, published in January 2019, identifies cardiovascular disease, diabetes,

stroke and respiratory as major health conditions which require further care. NHS Right Care (March

2020) further supports the opportunities of improvement in these areas as well as neurology.

The strategy will therefore focus on cardiovascular disease, diabetes, neurology and respiratory LTCs

within East and North Hertfordshire as a priority.

It is recognised there are additional LTCs. The general recommendations can be applied across

multiple conditions. The strategy recommendations can also be applied to post COVID-19

rehabilitation needs.

The strategy will deliberately not focus on specialist and high level mental health services; services

defined as planned care or urgent care; and conditions requiring immediate health care

interventions such as cancer. This does not diminish the importance of these services but there are

other programmes in place to support this work, including the Hertfordshire Dementia Strategy and

the Hertfordshire and West Essex STP ‘An Integrated Health and Care Strategy for a Healthier Future’

(2018). The challenge for the Long Term Conditions Board will be to ensure communication is

maintained between all key programmes.

The strategy will focus on the adult population (aged 18 years and over), with an additional focus on

BAME (Black, Asian and Minority Ethnic) communities to support the reduction in health

inequalities. The NHS Long Term Plan (2019) referenced that parts of the population, including

BAME communities, are at a substantially higher risk of poor health and early death compared to the

rest of the population. This inequality has further been emphasised by the impact of COVID-19 on

these communities.

The Long Term Conditions Board will collaborate with children’s commissioners to ensure transition

from paediatric to adult services is as seamless as possible for children with LTCs.

1.4.1 NHS Long Term Plan

The NHS Long Term Plan has been fundamental in framing this strategy and its recommendations.

The main objectives detailed within the NHS Long Term Plan are;

Transition the NHS to a new service model in which patients get more options, better

support and properly joined up care at the right time and in the right place

Strengthen the contribution to prevention and health inequalities

Establish priorities for care quality and outcomes improvement in the next decade

Tackle workforce pressures

Prevention is recognised as an important area whereby the NHS must complement the important

role already being undertaken by local government. A specific section has been included in this

strategy on prevention and its link to long term conditions.

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By moving away from the management of patients through single unconnected episodes of care, an

integrated and more proactive health care system will provide better support and outcomes for

patients with long term conditions. This should be undertaken in conjunction with improving self-

management education and support and a Population Health Management approach applied to all

transformation projects.

Due to their prevalence and impact on patients and the healthcare system; cardiovascular disease,

respiratory, diabetes and neurological conditions are specifically referenced in the Long Term Plan.

We have taken the decision not to focus on recommendations for specific conditions, but identify

the commonality across long term conditions to support the transition to a new service model.

Finally the NHS Long Term Plan sets an ambition to expand IAPT services for adults and older adults

with common problems, with a focus on those with long term conditions. Integration of mental

health services with physical health services is an ambition of the local health economy and

therefore has been specifically referenced within this strategy.

1.4.2 COVID-19 The COVID-19 pandemic necessitated a rapid response by the health and social care system to

respond to the unprecedented demand for acute healthcare services. The re-structuring and

suspension of services supported the management of COVID-19 patients but has resulted in a

significant proportion of unmet need across the rest of the population.

As the system moves towards recovery, along with planning for potential COVID-19 waves, there is

an opportunity to embed some of those changes; to ensure the system remains flexible in its

delivery; can manage surge demand and capacity and effectively use available resources.

The third phase of NHS response to COVID-19 reinforced the importance of ensuring recovery is

planned in a way that inclusively supports those in greatest need, including those with long term

conditions. The acceleration of preventative programmes which proactively engage those at greatest

risk of poor health outcomes is essential, as is the consistent risk stratification of patients and a

stratified approach to service delivery to support ongoing management.

2. BACKGROUND The NHS Long Term Plan (2019) recognises that LTCs are the biggest causes of premature mortality

and significantly impacts on a patient’s quality of life.

2.1 What are long term conditions?

“A long term condition (LTC) is a condition that cannot, at present, be cured but is controlled by

medication and/or other treatment/therapies”3

Long term conditions account for:

3 Department of Health (2012). Report. Long-term conditions compendium of Information: 3rd edition

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50% of all GP appointments

64% of all outpatient appointments

70% of all inpatient bed days – approximately 8 months of a year

In addition, around 70% of the total health and care spend in England (£7 out of every £10) is

attributed to caring for people with LTCs.4

Table 1: A table detailing the most common types of Long Term Conditions

DISEASE DESCRIPTION EXAMPLES

Respiratory

Diseases that affect the airways and lungs. Asthma Chronic Obstructive Pulmonary Disease

Cardiovascular

Diseases that affect the heart and blood vessels. Coronary Heart Disease Heart Failure Hypertension

Stroke Atrial Fibrillation

Chronic Kidney Disease

Endocrine

Diseases that affect the network of glands in the body that produce hormones to keep cells and organs functioning.

Diabetes

Neurology

Diseases that affect the nervous system. Epilepsy Parkinson’s Disease Multiple Sclerosis

2.2 Who is most at risk? People who are most at risk of developing a LTC are;

Individuals who already have a LTC

Individuals in lower socio-economic groups

Older people

People who are overweight, smoke, are physically inactive or who drink excessive alcohol

2.3 Local Context

East and North Hertfordshire has a population of around 610,000 people with healthcare provided

through a number of different organisations;

Primary Care: GP Practices and Pharmacies

Community Trust

Acute Trusts

Mental Health Trust

Hospices

Voluntary Sector

4 Ibid

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Public Health

The CCG is a patient-centred organisation. It aims to:

Work with patients, partners, managers and clinical colleagues from all sectors to

commission the best possible healthcare for our patients within available resources

Reduce health inequalities and achieve a stable and sustainable health economy by

working together, sharing best practice and improving expertise and clinical outcomes5

2.3.1 ENHCCG Population

Population Health Management will enable proactive understanding of patterns of admission and

will support the implementation of appropriate interventions. Key statistics for the ENHCCG

population are;

Life expectancy is above the national average for England; 84.1 years for a woman6

(compared to 83.1 years for England), 81 years for a man (compared to 79.6 years for

England)7.

59.8% of the East and North Hertfordshire population are aged between 20-64 years which

is in line with national statistics.

49,222 patients (2018/19 QOF Register) are recorded as obese. This is significantly fewer

than the estimated prevalence based on national statistics which states one third of adults

are obese and another third are overweight.

Nationally, 14.9%8 of adults are classified as current smokers and for Hertfordshire the

estimated prevalence is 12.7%9. For East and North Hertfordshire this would equate to

69,237 people (aged 16+).

90.3% of patients have their BP recorded in East and North Hertfordshire CCG, with 79.34%

receiving intervention for this (Public Health England). There is no metric for recording a

patient’s BP under the age of 45 years.

Although deprivation across the whole of Hertfordshire is lower than the national average

there are pockets of deprivation in East and North Hertfordshire.

87.6% of the total Hertfordshire population identified as White ethnicity within the 2011

census, whilst 12.4% identified as BAME. Whilst this data represents the whole of

Hertfordshire the proportion can still be applied across the East and North Hertfordshire

geographical area.

Nationally 5-8% of acute admissions to hospital are due to medication problems and up to

50% of patients do not take their medicines as prescribed

Please see ENHCCG Needs Analysis (2020) for further data.

2.3.2 Disease Prevalence 5 www.enhertsccg.nhs.uk/aboutus

6 Public Health England, Local Health Profiles (2016)

7 Ibid

8 2017 - Statistics on Smoking - England , 2018 - NHS Digital

9 Tobacco Control Strategic Plan for Hertfordshire - Public Health Hertfordshire

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The Quality Outcomes Framework (QoF) for 2018/19 provided data relating to the number of

patients registered with a LTC condition in ENHCCG.

Table 2: Quality Outcomes Framework Disease Prevalence Table (2018/19)

Register Prevalence Hertfordshire

and West

Essex

Respiratory Chronic Obstructive Pulmonary

Disease

9,584 1.55% 1.55%

Asthma 35,475 5.86% 5.71%

Cardiovascular Atrial Fibrillation 11,630 1.90% 1.92%

Heart Failure 4,314 0.69% 0.77%

Hypertension 81,206 13.42% 13.41%

Stroke 10,032 1.61% 1.55%

Endocrine Chronic Kidney Disease 13,562 2.85% 3.15%

Diabetes 28,962 5.93% 6.15%

Neurological Epilepsy 3,516 0.71% 0.69%

*Please note this data is for diagnosed patients only and not all conditions are captured.

2.3.3 Emergency Admission COVID-19 had a significant impact on non-elective emergency admissions to acute hospitals with an

unprecedented reduction during the peak of the pandemic. As attendances being to return to pre-

COVID levels the support to manage patients in the community and other care settings is even more

important.

NHS Right Care (2020) identified the CCG is an outlier amongst our peers for non-elective admissions

relating to respiratory, circulation and endocrine.

2.3.4 Mortality Data Public Health Fingertips data (2013-15) confirms Hertfordshire is below the national average for

both preventable mortality and premature mortality in people under 75 years for cardiovascular

disease and respiratory (all persons). However there are opportunities for improvement at a local

level compared to similar CCGs.

NHS Right Care (2020) highlighted opportunities for improvement in mortality from respiratory

conditions under 75 years and mortality from CHD under 75 years.

2.4 The current model of care Currently stable patients are managed in primary care with the option of onward referrals to

specialist community, secondary (acute) services and tertiary services if required.

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This model of care means that if a patient’s condition deteriorates, their care is led by secondary

(acute) services and the patient can remain in specialist services for longer periods of time (Cycle A

to D) due to periods of instability. This is further impacted as management is not always cohesive

between different services. Patient education and patient self-management is not widely and

consistently embedded therefore the quality and impact of patient education is variable.

Figure 1: A diagram depicting the current model of care

2.5 The future model of care

As part of the ‘Integrated Health and Social Care Strategy for a Healthier Future’, Hertfordshire and

West Essex STP set out a blueprint for delivering integrated, good quality care for the area. The

vision is summarised in the following diagram and depicts the overarching principles this strategy is

trying to achieve;

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Figure 2: Hertfordshire and West Essex STP Strategy Overview

The emphasis of transformation must be towards the integration of models of care that break down

the organisational boundaries that currently exist. A Population Health Management approach will

drive efficient commissioning by understanding and delivering services based on the needs of the

East and North Hertfordshire population.

Patient centred care, coordinated care, personalised care and services that are stratified and

responsive to the needs of the patient are prominent in the Hertfordshire and West Essex STP

diagram and must be at the core of LTC services. Importance needs to be placed on enablers such as

data, digital opportunities and wider organisations, such as charitable and voluntary sector to

support the delivery of transformation.

2.6 Patient Experience (i) Patient/Carer Survey

The CCG developed an online survey to understand the local experience of people living with or

caring for someone with, a LTC.

55 people completed the survey; the majority of whom were aged between 56-70 years. 77% of

those who participated in the survey were patients whilst the remaining 33% identified as a carer of

someone with a LTC. In response to the question, “which long term condition(s) do you have?” the

responses were as follows;

Neurology: 21.15%

Diabetes: 23.08%

Cardiovascular: 11.54%

Respiratory: 23.08%

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Other: 61.54% (particularly mental health and pain-associated conditions) (Please note patients had the option to select more than one long term condition)

When developing the strategy, The Healthwatch Hertfordshire survey, “The NHS Long Term Plan:

Views From Hertfordshire” (2019) understanding residents’ views and experiences was also

considered.

Respondents to the survey highlighted patients need timely access to help and treatment when

needed. People want to be able to stay in their home for as long as it is safe to do so.

Overall there is a need for greater access to treatment and support, as well as timely and consistent

communication.

(ii) Patient/Carer Co-Production Workshop

The CCG also held two Patient/Carer Co-Production Workshops;

January 2019: The first at the beginning stage of the Strategy development to obtain initial

feedback and experience that could be incorporated in the first draft of the strategy

October 2019: The second to review the draft LTC Strategy and obtain further feedback

regarding positive experiences, areas of concern and suggestions for improvement.

3. PREVENTING LONG TERM CONDITIONS AND CO-MORBIDITIES

Importance Addressing social determinants of health is key in protecting and promoting wellbeing and healthy living

Strategic Ambition To ensure that pathways and models of care link into non-NHS services that support wider detriments of health and primary prevention, e.g. social, environmental and behavioural interventions and services

To utilise the assets of non-NHS organisations (including the charitable and voluntary sector by increasing collaboration between NHS and non-NHS organisations)

3.1 What affects our health and wellbeing?

The key to preventing LTCs lies within the individual and their willingness to make lifestyle changes.

Childhood experiences, housing, education, social support, family income, employment,

communities and access to health services, all contribute to our health and well-being and are

referred to as the social determinants of health.

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Figure 3: Social Determinants of Health Dahlgren G, & Whitehead, M.(1993)

Addressing these determinants is key to protecting and improving individual health and wellbeing

whilst reducing health inequalities.

3.2 The role of the CCG in preventing and managing long term conditions The role of the CCG is to get the best possible health outcomes for our local population. This involves

understanding the needs, deciding the priorities and planning services that meet the need. In order

to do this, East and North Hertfordshire CCG buys services from organisations which provide patient

care, including NHS hospitals, mental health and community trusts, voluntary and independent

organisations. However this can lead to fragmented service provision which is good at managing

individual issues, but is less useful in preventing ill health and managing multiple conditions.

If the Health Economy is to respond to the rising demand for LTCs and co-morbidity-based care, a

shift in the way resources are deployed is required. There is an increasing need consider the whole

person with a holistic approach. Progress and change cannot be made without organisations working

together and the CCG has a role to play in bridging organisations. The COVID-19 pandemic has begun

to break some of those barriers and prompted effective integrated working and different methods of

service delivery.

Identifying wellbeing and preventing ill health should become a priority in order to prevent the

development of LTCs as well as improve patients’ quality of life and reduce disease progression. This

is also recognised in the NHS Long Term Plan.

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3.2.1 Obesity “Obesity and poor diet are linked to Type 2 diabetes, high blood pressure, high cholesterol and

increased risk of respiratory, musculoskeletal and liver diseases”10

This is usually identified by measuring an individual’s Body Mass Index (BMI) (a calculation based on

a ratio) and is considered the preferred measure by the National Institute for Health and Clinical

Excellence (NICE).

Figure 4: Body Mass Index Categories (NICE)

**It is important to note that although the above are the widely recognised as weight measurements , this

does vary depending on ethnicity as people from a South Asian background would be regarded as a healthy

weight up to 23kg/m2 .

People who are obese are at high risk of developing long term conditions such as type 2 diabetes,

coronary heart disease as well as mental health. Although Tier 1 and 2 weight management services

are the responsibility of Public Health to commission, the CCG has a role to play through promoting

these services and supporting patients to access and engage.

3.2.2 Alcohol Measuring the prevalence of alcohol consumption is difficult as self-reported statistics such as those

collected by the Office of National Statistics and the Health and Safety Executive tend to be dogged

by under-reporting, as well as lacking data from vulnerable populations such as the homeless.

3.2.3 Hypertension Hypertension is a major risk factor for stroke, heart failure, chronic kidney disease, dementia and

eye damage, leading to premature morbidity and mortality.

Hypertension can be predisposed by both non-modifiable risk factors such as age, gender and

ethnicity, as well as modifiable risk factors such as physical activity, alcohol, obesity, and mental

health problems (Public Health England). Treatment and lifestyle changes can help to control high

blood pressure and therefore reduce the risk of life-threatening illness.

3.2.4 Smoking

People who smoke are at greater risk of developing a LTC or additional LTCs. The Tobacco Control

Strategic Plan for Hertfordshire (Public Health Hertfordshire) has a priority of reducing the smoking

prevalence in the general population by at least 1% per year. The CCG supports the delivery of this

ambition through the alignments of policies and strategies.

10

Long Term plan

13-18 kg/m2

Underweight 19-24 kg/m2

Healthy Weight 25-29 kg/m2

Overweight 30+ kg/m2

Obese

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The NHS Long Term Plan has set a goal that “by 2023/24 all people admitted to hospital who smoke

will be offered NHS-funded tobacco treatment services”11 .

It is the role of the CCG and the ICP to support Public Health in the prevention agenda through

alignment of policies and strategies.

4. IDENTIFICATION, DIAGNOSIS AND STAGING

Importance Identifying, diagnosing and staging of LTCs at the earliest opportunity

can ensure patients are placed on the appropriate care pathways to

maximise outcome opportunities

Strategic Ambition To increase the detection of LTCs in line with expected levels

based on our demographic profile

To increase the staging of disease at the point of diagnosis for

LTCs

To detect disease at an earlier stage to minimise the risk of

disease progression and improve outcomes

Diagnosing patients in a timely manner provides the opportunity to reduce the complications of

LTCs, which lead to patient morbidity and emergency admissions. Early diagnosis also provides the

patient with time to engage in educational programmes and beneficial services, to aid self-

management and enabling individuals to stay well for longer.

4.1 Identification

There are a number of established mechanisms to support the detection of patients with potential

LTCs (see 4.1.1-4.1.3). GP practices can also be supported to proactively identify this vulnerable

cohort through case finding and monitoring.

4.1.1 NHS Health Check

The NHS Health Check is a check-up for adults aged 40-74, designed to identify individuals who

might develop stroke, kidney disease, heart disease, type 2 diabetes or dementia. The health check

takes into account the individual’s lifestyle and risk profile to find ways to lower the risk of

developing one of the above conditions. Individuals over the age of 74 have a named accountable

GP, who is responsible for providing a health check on request.

4.1.2 Learning Disability Annual Health Check

People with a learning disability often have poorer physical and mental health outcomes. Any

individual aged 14 or over, and who is on their GPs Learning Disability register is entitled to an

annual health check. This ensures that individuals with a learning disability can discuss their health

and identify problems early.

11

Ibid

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4.1.3 Severe Mental Illness (SMI) Health Check Individuals living with severe mental illness (schizophrenia, bipolar affective disorder, or who have

experienced an episode of non-organic psychosis), have one of the greatest health inequality gaps in

England. Often the physical health of these individuals is overlooked – the life expectancy of people

with SMI is now 15-20 years below that of the general population. More than 40% of adults with SMI

smoke, but they also have double the risk of obesity and diabetes, three times the risk of

hypertension and five times the risk of lipid imbalances, compared to those without a diagnosis of

SMI.

Individuals on the SMI register should have a physical health check at least annually. (NICE CG185,

CG178). This should align with the NHS Health Check, but should also be mindful of any additional

needs.

4.2 Understanding and Accepting Diagnosis A diagnosis can bring with it new medications, multiple appointments and the need to make

significant lifestyle changes. All of these factors can raise questions and concerns about how an

individual’s diagnosis may affect their work, family and social life.

Education is key to empowering patients to manage their own health, but needs to be delivered to

the patient at an appropriate time. Individuals should be signposted to reliable sources of

information in their chosen format. In many cases, people close to the patient may also wish to be

involved and have questions about how best to support them.

For some individuals, a new diagnosis of a LTC can impact their mental health. Appropriate levels of

support should be accessible to all newly diagnosed patients.

4.3 Disease Staging Disease staging is used to assess the severity of an individual’s disease. ENHCCG GP Practices

already routinely review their patient records to ensure that every patient with a diagnosis of COPD

has a GOLD (A-D) score recorded. This is the recognised risk stratification for COPD.

5. LIVING WITH A LONG TERM CONDITION – A PROACTIVE APPROACH

Importance Patients and their carers need to be empowered to take responsibility

for their own healthcare.

Strategic Ambition To increase the level of patients feeling enabled to self-manage

their LTC

To provide information and advice at the point of diagnosis to

support patients to understand their condition and what they

can do to manage their health

To provide ongoing education, advice and support, tailored to

their level of need and personal circumstances to continue

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supporting patients to manage their level of engagement and

activation

To effectively use social prescribing resources to increase uptake

of new ways of managing LTCs and associated risk factors

All patients with a LTC will have a health and wellbeing reviewed

and care optimised, (including medication reviewed, goals

identified etc) and where appropriate a care plan documented

and shared with the patient and other relevant providers.

To proactively identify patients at high risk of an adverse event

(e.g. an emergency admission)

To identify and support mental health needs for people with a

long term physical health condition.

5.1 Patient Activation

“I can plan my care with people who work together to understand me and my carer(s), allow me

control and bring together services to achieve outcomes important to me”12

National Voices (2013)

Patient activation describes the knowledge, skills and confidence a person has in managing their

own healthcare. The King’s Fund states that” patients with low activation levels are more likely to

attend accident and emergency departments, to be hospitalised or to be re-admitted to hospital

after being discharged. This is likely to lead to higher health costs”13. Therefore patients with high

levels of activation are more likely to engage with their healthcare services and self-manage their

condition more effectively.

For patient’s to successful engage in their health, effective interventions need to be available that

are tailored to an individuals’ level of activation. This will provide a targeted approach most suited to

patient need with the aim of increasing their activation levels.

The Health and Social Care Act (2012) identified that care should be integrated around the needs of

the individual, and that people should be able to make decisions about their own care.

70-80% of people with a LTC can care for themselves with minimal input from health and social care

services. People with LTCs will spend only a few hours a year with a health care professional and

much of their life managing their condition independently. They will be responsible for making the

day to day decisions about their health and in order to do so, are required to become experts in their

own health and wellbeing. The health care system needs to support individuals to develop their

skills, knowledge and confidence, however, self-management is not just about enabling individuals

to self-care. Individuals should be empowered to make choices about their treatment and care

through shared decision making.

12

National Voices (2013) “A narrative for Person Centred Coordinated Care” 13

The King’s Fund (2014) “Supporting people to manage their health: an introduction to patient activation”

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People are able self-manage their condition if they:

1. Can access appropriate information and advice at the right time from the right person

2. Feel confident in managing their condition

3. Are better informed about their condition(s) and how to manage it

4. Are supported to make decisions about their health care through shared decision making

5. Have a clear plan so that they (or the people around them) know what to do if their

condition worsens

6. Have access to digital technology to help track and manage their condition

7. Are treated as a whole person rather than by individual diseases

8. Can access peer support

The self-management of long term conditions can “result in a slower disease progression, fewer

planned and unscheduled acute episodes and shorter lengths of stay”14.

In order for people to be supported to self-manage their conditions they require:

1) Access to up to date and reliable information

2) Education on their specific condition and what it means for them

3) Support to increase their confidence in managing their condition

5.2 Patient Education

5.2.1 Access to Information

79.59% of people surveyed felt confident in accessing advice relating to their condition and the

majority of this (91.84%) was sourced from the internet. However the group also reported barriers in

accessing this information including;

Sparse knowledge of what is available, including local resources

Not knowing what questions to ask

Lack of face to face time with specialists particularly if you have mobility and/or transport

issues (The delivery of education will need to be considered following COVID-19)

Too much information online, which can be contradictory, overwhelming or confusing

5.2.2 Education

Education is necessary not only at the point of diagnosis, but throughout the life-time of the

individual. Education can be provided in a number of ways from webinars and online programmes to

short informative text messages and posters in health and social care settings.

There are a number of education programmes already in existence however the quality and

accessibility within each programme can vary across the different LTCs. In order to reduce this

variation, there needs to be a review of what currently does and does not exist, costs and

accessibility.

It is also important to involve those who support the patient, although this person may not

necessarily be identified as a carer.

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Self-management plans are often provided to patients, but without education on what they are and

how to use them they are of little use. Plans are often paper based and with the increasing advances

in digital technology there is a need to explore additional mechanisms. COVID-19 has accelerated

the development and utilisation of digital platforms to support patient management. As part of the

review of education it is important that digital technology is considered, not only in education but

also in communication between patient and clinician.

Education on LTCs should also be adaptable to take into account lifestyle factors that can affect

individuals. It needs to be tailored to individuals to take account of specific cultural needs and/or

learning abilities. In every form of education, consideration must be given to how this is accessible to

carers and the support that can be provided to them.

5.3 Social Prescribing

Social prescribing enables healthcare professionals to refer patients to a link worker, to co-design a

non-clinical social prescription to improve their health and wellbeing. They connect people to

community groups and statutory services for practical and emotional support.

This is a crucial resource to support and extend primary care prevention and to support the

management of risk factors.

Figure 5: Social Prescribing Model

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5.4 Co-ordinating Care Valuing people as active participants in the planning and management of their health leads to improved wellbeing, satisfaction and experience of healthcare. 60% of CCG patients surveyed stated they did not currently have a care plan, and a further 17% were unsure of their care plan status. Developing patient-based solutions also improves patient compliance and means that management plans are appropriate to the individual, improving the chances of patients receiving the support they need. Care planning is recommended by NICE, and its guidance suggests that care plans should include:

Changes in medication and other treatments

Prioritising healthcare appointments

Anticipating changes in a patient’s health and wellbeing

Assigning responsibility for care coordination and ensuring this is communicated to other people involved in the patient’s care

Other areas the person considers important to them

Arranging a follow-up and review of decisions made

The successful management of a long-term condition requires a multidisciplinary approach, working in conjunction with patients, carers and family. Therefore it is important to ensure care plans are in an accessible format and (with the patient’s permission), shared with the other people involved in their care, to ensure their agreed plans are recognised by all who support them.

5.4.1 Shared Decision Making At the heart of personalised care is shared decision making - a process in which people are supported by clinicians to a) understand the care, treatment and support options available and b) make a decision about a preferred course of action, based on evidence-based, good quality information and their personal preferences. It can create a new relationship between individuals and professionals based on partnership and reduce unwarranted clinical variation.

A good shared decision making process will mean that:

• people are aware that care, treatment and support options are available, that a decision is

to be made and that the decision is informed by knowledge of the pros and cons of each

option and ‘what matters to me’

· clinicians are trained in shared decision making skills, including risk communication and

appropriate decision support for people at all levels of health literacy and for those groups

who experience inequalities or exclusion

• well-designed, evidence-based decision support tools are available and accessible

• shared decision making is built into relevant decision points in all pathways

5.4.2 Annual Review

It is important to ensure that individuals are followed up on an annual basis to ensure their condition

has not deteriorated, their medications are still appropriate and to perform necessary monitoring

(e.g. blood tests). It is also an opportunity for patients to discuss any aspect of their condition that

may be causing them concern. Annual reviews are not necessarily carried out by the patients’ GP; it

may be that if an individual has a complex long-term condition that this is best done by their hospital

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specialist. However, the patient should be clear what an annual review looks like for them and who

will undertake it.

Due to COVID-19 there is a backlog of patients that have not had their annual review or not had all

elements completed due to it being a non-face-to-face consultation. The system will need to be

supported in developing a recovery plan to manage this backlog.

When surveyed, 62% of CCG respondents with long term conditions advised that they had not had a

review of their condition within the last 12 months.

5.5 Medicine Optimisation

Medication is the most common form of healthcare intervention. The majority of patients diagnosed

with a LTC will be reliant on long term medicine use. Medicine optimisation is therefore crucial in

ensuring medicines are both clinically and cost effective; this will support an improvement in health

outcomes, reducing medication waste and improving medicine safety.

Figure 6: Medicines Optimisation (NHS England)

The CCG’s patient survey found that 53% of people surveyed took more than 5 tablets/medicines on

a daily basis, and 60% would like this to be reduced if possible. The vast majority (91%) of all survey

participants understood the reasons behind the prescription of these medications, yet only 68%

indicated that they were fully informed of any changes to their medication and the rationale for

doing so.

The focus for effective medication optimisation in patients with LTCs should include;

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Structured medication reviews: Ensuring there are structured, holistic and personal reviews

of a patient’s medicine regime

Medicine optimisation: Supporting patients to get the best from their medicines

Reducing unnecessary polypharmacy: Reducing the number of unnecessary and/or

ineffective medication prescribed to patients

Patient education: Increasing patient knowledge of their medication including purpose,

interactions with other drugs and side effects

Workforce: Developing the emerging pharmacy workforce in primary care and supporting

the integration of community pharmacy services to support better outcomes in LTCs

5.6 Mental Health

It is estimated that 30% of all people with a LTC have a co-morbid mental health problem15. These can lead to significantly poorer health outcomes and reduced quality of life.

There is particularly strong evidence for a close association between cardiovascular diseases,

diabetes and chronic obstructive pulmonary disease (COPD), and conditions such as depression and

anxiety.

In order for people to be able to manage their long term condition their emotional and psychological

needs must also be met. This should be integrated with their physical health care services where

possible however it is recognised that some patients may require specialist mental health services.

6. MANAGING MULTIMORBIDITIES

Importance A patient with multi-morbidities requires a more enhanced care than an individual with one LTC. A co-ordinated and MDT focused approach to the management of multi-morbidities, alongside patient activation and engagement will better support patients.

Strategic Ambition To commission an integrated and specialist led MDT approach to the management of multimorbidities

To increase the staging of disease during disease reviews

To commission services that provide a stratified approach to patient management

To proactively identify and manage patient risk factors

To support improved information sharing across organisational and care systems

6.1. What are multi-morbidities?

As people live longer there is an increased possibility that they will develop multi morbidities

(additional diseases/conditions) or complications relating to their long term condition.

“People with multiple conditions have poorer health outcomes, poorer experiences of care and are

more likely to report care coordination problems”.16

15

Cimpean D, Drake RE (2011) “Treating co-morbid medical conditions and anxiety/depression”

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Sometimes having a particular long term condition will increase the likelihood of developing a

second. However, it is possible to have two or more conditions that develop independently from

each other. The exacerbation of one condition can impact on another.

One in two people with a multi-morbidity report a lack of information about conditions or treatments, poor communication between healthcare professionals, and waiting times to see a specialist.17

Continuity of relationships is more difficult to enable when care and responsibility is shared across multiple settings. This poses a particular challenge in primary care, where continuity of care – triggered in part by the large numbers of consultations required for people with multimorbidity – can be difficult.18

6.2 Preventing multi-morbidities

Long term conditions are more prevalent with increasing age, and with this comes the increasing

likelihood of an individual having more than one long-term condition. Multi-morbidity is also more

common among deprived populations, especially where one of the diagnoses is a mental health

problem.

By addressing the known risk factors for long-term conditions discussed in chapter 3; the likelihood

of them developing a subsequent condition will be reduced. However it needs to be recognised that

whilst these risk factors are modifiable, they do not occur in isolation and must be viewed holistically

with the patient to ensure appropriate and achievable targets are set.

In addition for those with long term conditions that specifically increase the risk of another

developing it is vital that patients receive education and self-management strategies to reduce their

chance of decompensation or exacerbation.

6.3 Supporting people with multi-morbidities

Living with and successfully managing a long term condition can require support from many facets of

the health and social care system. The complexity of this can increase dramatically for patients who

are diagnosed with more than one long term condition. Increasing numbers of medications,

alongside multiple appointments can cause patients frustration and anxiety about the best way to

manage their health.

For this group of patients it is especially important that their health and the management of their

long term conditions are viewed holistically; with the understanding of how one condition or

treatment may impact another aspect of their health or lived experience, and how this is most

appropriately managed.

16

https://richmondgroupofcharities.org.uk/taskforce-multiple-conditions 17

Adeniji C et al. (2015). What are the core predictors of ‘hassles’ among patients with multimorbidity in primary care? A cross sectional study. BMC Health Serv Res 15: 255. 18

Salisbury C et al. (2011). Epidemiology and impact of multimorbidity in primary care: a retrospective cohort study. Br J Gen Pract 61(582): e12–e21.

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By empowering individuals to take part in ongoing discussions about their care and planning for the

future; the concerns about managing several conditions, multiple medications and different teams

of health professionals can begin to be ameliorated.

Many individuals with multi-morbidities are looked after by several teams of health professionals,

social care and other independent or voluntary organisations. As commissioners, it is vital to

understand the role that all of these organisations play in supporting an individual with multi-

morbidities. It is key that all relevant organisations are consulted with and their opinions and skills

are taken into account. Specialist services should focus on highest risk patients and on intervening at

the most appropriate rime rather than routine management.

6.4 Workforce

It is essential that NHS staff, and wider system colleagues, get the support they need to do their jobs

effectively. The interim NHS People Plan sets out a number of ambitions that are relevant to this

strategy including;

Making sure that people have the right skills to help care for patients

Empowering the workforce to use new technology

Utilising alternative workforce models to strengthen the robustness of the service and

promote a MDT approach to patient care

7. PALLIATIVE AND END OF LIFE CARE

Importance Palliative care provides important pain and symptom management and

a higher quality of life for patients until their death.

Strategic Ambition To systematically identify patients with a LTC who are in the last year of life

To ensure that patients in the last year of life have an advanced care plan, including escalation plan, anticipatory medications and a discussion around DNACPR

To focus on the needs of the patient to understand what is important to them and ensure patients are plugged into the appropriate services

To ensure that patients at the end of life stage of their LTC receive appropriate care and are supported to remain in their preferred place of residence

Palliative care aims to improve the quality of life for people with life-limiting illnesses, by controlling

symptoms. It also helps patients and families deal with emotional, spiritual or practical issues arising

from the illness and is not reserved for patients at the end of their life.

People suffering from any incurable progressive illness may require palliative care - for example,

those with heart failure, advanced respiratory disease, dementia, and the end stages of progressive

neurological diseases or cancer.

Despite this, the majority of palliative care inpatients (88% of palliative care inpatients and around

75% of new referrals to hospital support and outpatient services in the UK (excluding Scotland)) are

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for people with cancer19. This suggests people with non-cancer conditions may face barriers to

accessing palliative care.

Regardless of the disease, more than 50% of people in need of palliative or end of life care will

experience pain, breathlessness and fatigue20. The palliative and end of life service in East and North

Hertfordshire can support people to manage these three symptoms and so more should be done to

ensure these people are accessing the services. They can also provide education in self-management

of symptoms.

Locally there has been a lot of work undertaken to improve the links between palliative and end of

life care providers and LTCs. The focus has particularly been in regards to dementia, respiratory

diseases and heart failure. As a result, there has been a significant shift in the proportion of non-

cancer patients accessing hospice care.

8. CONCLUSION

ENHCCG recognises the importance of effective identification and management of LTCs. COVID-19

has created a greater challenge in this regard but also has prompted new ways of working which can

be adapted and adopted for the benefit of the healthcare system and its patients.

Successful transformation of LTC services will require a multi-stakeholder approach from across the

system and its wider partners. Primary care prevention is crucial in supporting the wellbeing of

patients. Improved detection and diagnosis will enable patients to be placed on the most

appropriate care pathway at the earliest opportunity. Better coding and increased staging of disease

at the point of diagnosis will support the CCG to apply a Population Health Management approach to

commissioning of stratified services, that will support patients from diagnosis through to disease

management, including proactive crisis response, to palliative and end of life care.

Ambitions within this strategy have been set to meet this challenge. The delivery of the

implementation plan (see Appendix One) will require collaboration with all organisations that

provide care and support for patients with a LTC and their carers.

The desired outcome is to ensure East and North Hertfordshire has a sustained, integrated and

holistic healthcare system for patients with a LTC.

19

National Survey of Patient Activity Data for Specialist Palliative Care Services 20

Dixon et al, Equity in the provision of palliative care in the UK: review of evidence (2015)

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APPENDIX ONE: IMPLEMENTATION PLAN

Ambitions Year 1 Year 2 Year 3

Prevention

To ensure models of care

support the wider

determinants of health and

primary prevention

To utilise the assets of non-

NHS organisations

To map the service provision of Care

Navigators and/or Social Prescribers

across ENH

To update ENH pathways (and

clinical systems where appropriate)

to reflect the prevention service

offer (including how patients access

social prescribers and care

navigators)

To ensure an online resource is

available for patients to self-refer to

prevention programmes

To map the prevention services

available

To signpost to Public Health

initiatives such as befriending,

volunteering and social support

groups and non-NHS organisations

To ensure patients with LTC

(Diabetes, CVD, Respiratory and

opportunistic) have their risk factors

recorded (height, weight, BMI,

alcohol use, and smoking status)

To ensure patients with LTC

(Neurology, CKD and opportunistic)

have their risk factors recorded

(height, weight, BMI, alcohol use,

and smoking status)

To ensure patients with LTC (Stroke,

TIA, Atrial Fibrillation and

opportunistic) have their risk factors

recorded (height, weight, BMI,

alcohol use and smoking status)

To improve communication that

reflect the needs of vulnerable

isolated groups, those with low

literacy or learning difficulties, and

people who do not use digital or

social media

To populate a Population Health

Management Pyramid for COPD,


Management Pyramid for Asthma,


Management Pyramid for other LTCs

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Heart Failure and Diabetes Atrial Fibrillation, Stroke and

Parkinson’s Disease

(to be determined)

Identification

To increase the detection of

LTCs

To detect disease at an

earlier stage

To increase the staging of

disease at the point of

diagnosis for LTCs

To support Public Health to increase

the number of eligible patients

undertaking a NHS Health Check

To support Public Health to increase

the number of eligible patients

undertaking a SMI/Learning

Disability Health Check

To support case finding in primary

care for patients with suspected

COPD and/or breathlessness

To support case finding in primary

care for patients with suspected LTCs

(to be determined)

To support acute discharge reviews

where the patient’s diagnosis is

unknown in primary care

To ensure all patients diagnosed

with COPD have an appropriate

GOLD status coded

To ensure all patients diagnosed

with Heart Failure and Chronic

Kidney Disease have the appropriate

disease staging coded

To work collaboratively with PCWEN

to undertake a gap analysis of

workforce training needs to support

earlier and appropriate diagnosis

To improve the access to diagnostics

for those most likely to have

undetected disease (i.e. Spirometry

– COPD)







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Heart Failure and Diabetes Atrial Fibrillation, Stroke and


(to be determined)

Management

To provide information and

advice at the point of

diagnosis

To provide ongoing

education, advice and

support

All patients with a LTC will

have a health and wellbeing

reviewed and care

optimised

To proactively identify

patients at high risk of an

adverse event (e.g. an

emergency admission)

To increase the level of

patients feeling enabled to

self-manage their LTC

To identify and support

mental health needs for

people with a long term

physical health condition

To map the information available to

patients (and staff) at the point of

diagnosis

To develop required information for


diagnosis

To develop required information for


diagnosis

To map the education available

throughout disease progression,

including methods of delivery

To develop required education for

specific LTCs (to be determined)

To develop required education for

specific LTCs (to be determined)

To research digital platforms for the

delivery of education,

communication and remote

monitoring

To develop a structured self-

management programme for

patients with low levels of activation

To develop a structured self-

management programme for

patients with moderate levels of

activation

To link LTC education programmes

with national communication events

and local initiatives

To increase the number of annual

reviews for COPD, Heart Failure and

Diabetes; ensuring disease staging is

reviewed and updated, medication

optimised and care plan in place


reviews for Asthma, Atrial

Fibrillation, Stroke and Parkinson’s

Disease; ensuring disease staging is

reviewed and updated, medication

optimised and care plan in place


reviews for LTCs (to be determined);

ensuring disease staging is reviewed

and updated, medication optimised

and care plan in place

To integrate mental health services

with Respiratory, Heart Failure and

Diabetes


with CVD, Stroke and Neurology


with other LTCs (to be determined)

To identify a targeted cohort of

patients at risk of adverse events (to

To identify a targeted cohort of

patients at risk of adverse events (to

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be determined) and apply a case

management approach

be determined) and apply a case

management approach



Heart Failure and Diabetes



Atrial Fibrillation, Stroke and




(to be determined)

Multi-Morbidity

To commission services that

provide a stratified

approach to patient

management

To support improved

information sharing across

organisational and social

care systems

To commission an

integrated and specialist led

MDT approach to the

management of multi-

morbidities

To increase the staging of

disease during reviews

To proactively identify and

manage patient risk factors


reviews for complex patients (to be

determined) ensuring disease

staging is reviewed and updated,

medication optimised and care plans











To consider alternative delivery

models of care, including alternative

workforce, and training

requirements




requirements




requirements

To develop an integrated Respiratory

service model and the ability to scale

up to other disease groups

To develop an integrated service

model for LTCs (to be determined)










(to be determined)

End of Life/Palliative Care

To focus on the needs of the To identify patients within the last

year of life using the GSF

To identify patients within the last


To identify patients within the last


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patient to understand what

is important to them and

ensure patients are plugged

into the appropriate

services

To ensure patients at the

end of life stage of their LTC

receive appropriate care

and are supported to

remain in their preferred

place of residence

To systemically identify

patients with a LTC who are

in the last year of life

To ensure that patients in

the last year of life have an

advanced care plan,

including escalation plan,

anticipatory medications

and a discussion around

DNACPR

methodology methodology methodology

To develop/ensure a rolling training

programme for staff regarding

advanced care plans, symptomatic

management of EOL care (care

homes) and having difficult

discussions






discussions






discussions










(to be determined)

Long Term Conditions Strategy 2021-2025

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