1. LTC South West Ambitions

2. DISCUSSION DOCUMENT
Prevalence of specific long-term conditions
Prevalence of Long-Term Conditions known to GPs through QOF
As part of the Quality and Outcomes Framework (QOF) GPs are rewarded for compilation of registers of the
prevalence of certain long-term conditions. These registers show that almost one in eight people in England are
being treated/monitored for hypertension and one in seventeen people are being treated/monitored for asthma.
Prevalence of QOF conditions, 2005-06
14%
Unadjusted Prevalence (% of population)
6.37
12%
NHS Next Stage Review
10%
8%
Prevalence in millions
3.1
6%
1.9 1.89
4%
1.26
0.73 0.83
2%
0.38 0.32 0.23 0.32
0%
Asthma
Cancer
COPD
Coronary Heart
Diabetes
Epilepsy
Hyper-tension
Hypo-thyroidism
Left Ventricular
Mental Health
Stroke and TIA
Dysfunction
Disease
*
QOF Condition
Source: Quality and Outcomes Framework 2005-06, Health & Social Care Information Centre
5

3. South West
• Five million population
• 17.4% registered with LTC (870,000)
Most Recent Census
• 70-74 39.9%
• Over 90 74.1%

4. Immediate Areas for Improvement
• Promoting health, disease prevention and self-care
• Meeting the 18 week target for elective referral and providing
fast track services for urgent referral
• Reducing emergency admissions and delayed transfers of
care
• Further improving stroke services
• Improving mental health services for older people, including
dementia care
• Making available assistive technology and equipment
• Improving dignity in care in all settings
• Providing access to appropriate palliative care services

5. Local Examples of Best Practice
• Partnerships for Older People Projects
• Cornwall and Isles of Scilly falls prevention and
management
• ‘Look after your legs’ initiative in Gloucester,
• Age Concern in Devon to provide mentoring to
isolated older people
• Fast track services in Bournemouth and South
Devon, for people suspected of having a stroke;
• use of the FAST (Face-Arm-Speech-Test) scheme in
Cheltenham

6. Local Examples of Best Practice
• Improving housing pathways work in
Plymouth
• Pathways to Work Somerset
• Telecare programme in Gloucestershire
• Expert carers programmes, for example in
Bath and North East Somerset

7. Headings and Challenges
• Prevention
• Early Detection
• Proactive and Integrated Care
• Self Care
• Specialist Care
• Rehabilitation

8. Prevention
• local identification and ownership of the needs of
the community: Ensuring the Joint Health and Social Care Needs
Assessment, being undertaken by Primary Care Trusts and Local
Authorities across the South West, links effectively with local communities;
• organisational planning cycles: Ensuring alignment of
planning timetables for Local Area Agreements and Local Delivery Plans;
• shift in funding: Achieving flexible approaches to use of health and
social care funding to support the prevention agenda, ensuring this is
underpinned by strong governance arrangements.

9. Early Detection
• health inequalities: Ensuring information, personal to
circumstances, in range of styles and formats, is accessed by all social
groups especially those in areas of deprivation
• access to diagnostics: Improving direct community based
access to diagnostics with view to improving early identification and
management of long term conditions and resulting in a subsequent
decrease in number of referrals to secondary care specialist services

10. Self Care
• system change: Ensuring the concept of self-care is fundamental
to all long term condition services and interventions;
• information and advice: Making information and advice
available in local communities in a way that will encourage access by
individuals to support self care;
• professional understanding: Professional attitudes and
comments made to patients can, if solely based on a ‘medical’ model, be
detrimental to promotion of self care

11. Proactive and Integrated Care
• policy direction: Management of tensions between differing
government policies and minimising the risk this presents to achieving a
whole systems approach;
• organisational boundaries: These may include:
• differing organisational priorities including investment priorities;
• barriers between primary and secondary care;
• differing understanding of concepts and use of language between
organisations;
• capacity and capability: This includes supporting the
development of the third sector
• addressing rurality: Minimising the impact of rurality issues
on equity of access to services

12. Specialist Care
• commissioning flexibilities: improving flexibility to commission
for whole needs of an individual i.e. beyond health care
• professional specialisms: Professional specialisms can foster a
continued adherence to a medical model for long term conditions
• location of specialist care: Location of specialist care is
currently to a large extent within acute hospital settings and does not
support the shift to localised care in the community and the concept of
empowering the individual to manage his or her own condition
• data systems: Current data systems are not always in line with
current and planned models of care

13. Rehabilitation
• perception of rehabilitation: community based bio-
psychosocial rehabilitation model including community, social and
voluntary services
• long term condition skills base: Ensuring community services
achieve the critical mass required to achieve and maintain disease specific
skills within the workforce, whilst retaining a patient-centred approach to
care
• current rehabilitation model: Most rehabilitation models and
services operate within office hours, have limited availability out-of-hours,
are often only available in an inpatient setting, and within limited
timeframes, for example six or nine weeks

14. Concepts

15. All Partners
Public services,
Voluntary
organisations,
faith
communities
Health,
social care,
housing

16. Vision of for LTCs
Community
Input Social Input
Specialist
Input Medical
Input
Community Community
owned owned Care Pathway
Health Health Care Pathway
Inequality
Data
Campus Care Pathway

17. LTC Ambitions
• Ambitious re-alignment of our engagement
with LTC to reflect the change of direction in
acknowledging the patient as being the locus
of control for the condition with which they
are living on a day-to-day basis
• Health services should align themselves
around this patient rather than fitting the
patient around the health service

18. A joint health and social care
commissioning strategy
• plans for raising awareness of individuals and communities
around local health issues
• provision of good early information
• local initiatives which support people to access healthy
lifestyles
• structures and protocols for early detection and screening
• mechanisms agreed by which practice-based disease
registers can inform local commissioning and planning
• structures to support specialist provision closer to peoples
homes
• plans for structured approach to commissioning from
voluntary sector

19. Metrics

20. 1. Community HNA
• at least one local community within each
Primary Care Trust area has become engaged
in their own heath needs analysis in at least by
September 2008

21. 1. Health Campus
• each area has developed at least one Health
Campus based on the Community Health
Model through which lay people become the
local resource for their population

22. 1. Self Management Plans
• 75% of patients with one of the more
common long term conditions will have been
offered an action plan that supports self
management, by March 2009
– patient centred goals and outcomes
– describes what carers, agencies and professionals
will do
– supports individuals to cope with exacerbations,
crisis and changes

23. 1. General Practice
• over 75% of general practices to have adopted
the self care policy for their locality by July
2009

24. 1. Single Point of Access
• all Primary Care Trusts to establish a single
point of access or coordination system by
which they support their long term conditions
Health Campus to ensure existing range of
services both statutory and voluntary are
accessed appropriately by people with long
term conditions by March 2010

25. 1. Community Based Services
• all Primary Care Trusts to review existing
community based services to ensure a
coordinated multidisciplinary team approach
to the management of long term conditions,
reflecting local need and part of a managed
network of care, by 2010

26. 1. PBC and the Public
• Practice Based Commissioners will have
infrastructure in place through which patients
with long term conditions are fully involved in
the commissioning of their own services
including the development of choice where
appropriate by March 2009

27. 1. Specialist Services
• specialist input to long term conditions will be
re-specified from the community perspective
for at least three conditions by April 2009

28. 1. Public Experience Surveys
• performance management metrics will be
developed locally for each long term
conditions based on individual surveys of
patient experience in addition to more
traditional process markers