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Long Term Conditions Helen Walley


Only about 50% of medicines are taken as prescribed. National & Local. requirements ... Commissioned Data Collection and Project Management. Progress. so far ... – PowerPoint PPT presentation

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Title: Long Term Conditions Helen Walley

Long Term ConditionsHelen Walley
  • Strategy Development Workshop 7th January 2005

Supporting People with Long Term Conditions
Supporting People with Long-term Conditions
  • An NHS Social Care Model to support local
    innovation and integration
  • Published 5th January 2005

Current National and Local Requirements
  • The problem
  • Seventeen and a half million people in this
    country report a long term condition (such as
    diabetes, asthma or arthritis).
  • For some people, especially older people and
    those with more than one condition, discomfort
    and stress is an everyday reality.
  • The impact on the NHS and social care for
    supporting people with long term conditions is

National Local requirements
Current National and Local Requirements
  • Care for many people with long term conditions
    has traditionally been reactive, unplanned and
    episodic. This has resulted in heavy use of
    secondary care services.
  • Just 5 of inpatients, many with a long term
    condition, account for 42 of all acute bed days.
  • Only about 50 of medicines are taken as

National Local requirements
Current National and Local Requirements
National Local requirements
  • The strategic aim
  • To embed into local health and social care
    communities an effective, systematic approach to
    the care and management of patients with a long
    term condition.
  • To reduce the reliance on secondary care services
    and increase the provision of care in a primary,
    community or home environment.

Current National and Local Requirements
  • Patients with long term conditions need
    high-quality care personalised to meet their
    individual requirements.
  • The Public Health White Paper Choosing Health
    underpins the entire long term condition
    approach. This will build on the publics
    growing desire for a healthier future by ensuring
    that the self care support is in place for people
    particularly those in disadvantaged groups and
    areas to make healthier choices about diet,
    physical activity and lifestyle.

National Local requirements
  • PSA National Target -
  • To improve health outcomes for people with
    long-term conditions by offering a personalised
    care plan for vulnerable people most at risk
  • and to reduce emergency bed days by 5 by 2008
    (from the expected 2003/04 baseline), through
    improved care in primary care and community
    settings for people with long-term conditions.

Number of multiple admissions, 2002/3 all
diagnoses (long term and acute)
Number of people divide by around 2.5
Multiple admissions, Rate per 1000, 2002/3 all
diagnoses (long term and acute)
Selected long term conditions-
Number of multiple admissions, 2002/3, for SW
  • COPD 966
  • Heart failure 742
  • Angina 671
  • Asthma 365
  • Sickle cell 338
  • Epilepsy 293
  • Chronic ischaemic heart disease 247
  • Chronic renal failure 216
  • Diabetes (types I and II) 210
  • Hypertension 26

Progress so far
  • Established Steering Group
  • Chair Helen Walley
  • Membership
  • St Georges Hospital
  • Sutton Merton PCT
  • Pharmacist
  • Lambeth PCT
  • Strategic Health Authority
  • Mental Health Trust
  • Chelsea Westminster NHS Trust
  • Workforce Development Confederation
  • London Ambulance Service

Progress so far
Progress so far
  • Stakeholder Group

Progress so far
Progress so far
  • COPD
  • Diabetes
  • Older People with complex needs
  • Heart Failure
  • IT

Progress so far
Progress so far
  • Commissioned Data Collection and Project

Progress so far
Short and Medium Term Objectives
  • To establish function process
  • To gather the information about actual usage of
    services both secondary and primary care
  • To identify best practice
  • To disseminate, implement and monitor best
    practice guides
  • To agree outcome measures including patient

Short Medium Aims
What we need from the enabling strands
  • IT
  • Changes to workforce i.e. community matrons
    (expert patient programme)

Group Work 40 Minute Discussion
  • Do you understand what has been said?
  • Would you like to see anything else included in
    a) the vision b) the work of the group?
  • Is this special enough for Wandsworth
  • What links can you see with other parts of the
  • Are there any other comments you want to make?
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