Services for People with Long Term Conditions: Policy and Models of Care in the United Kingdom

1. Services for People with Long Term Conditions: Policy and Models of Care in the United Kingdom Jan Hull Acting Director of Development

2. Long Term Conditions • the UK health system • NHS policy for long term conditions • delivering improved services: the proposed model • emerging evidence on the new approaches • local implementation. 2 September 2005

3. The UK Health System 2 September 2005

4. Dorset and Somerset Strategic Health Authority • Counties of Dorset and Somerset • Combined population of 1.2 million • Approximately 26,000 NHS employees • 1,094 GPs in 178 Practices • 25 Community Hospitals • NHS expenditure of approximately£1.25 billion 2 September 2005

5. Long Term Conditions The WHO definition includes: • non- communicable conditions • persistent communicable conditions • long term mental disorders • ongoing physical/structural impairments 2 September 2005

6. The Challenge • Optimal management of chronic disease is one of the most complex and potentially costly challenges facing modern healthcare systems • 78% of healthcare spending (US data) • WHO estimates 75% of global population living with one condition, 50% with 2 or more • In the UK people with long term conditions use 60% of hospital bed days 2 September 2005

7. Increasing Policy Focus • burden of ill health and disability • increasing prevalence of long term conditions and related risk factors • high utilisation of services, particularly through unplanned admissions, by people with multiple conditions • learning from international models of care 2 September 2005

8. NHS Policy Context • Transforming services for people with long term conditions is now a central element of NHS policy • This commitment is set out in The NHS Improvement Plan (2003) and the current 3 year Planning Framework, ‘National Standards, Local Action’ • The model for delivering improved services ‘Supporting People with Long Term Conditions: An NHS and Social Care Model to support local innovation and integration’ was published in January 2005 2 September 2005

9. Emergency Bed Day Targets • national target of 5% reduction in emergency bed days by 2008 has been set • for Dorset and Somerset this equates to 36,000 bed days (baseline 858,000 emergency bed days in 2003/04) 2 September 2005

10. Shortfalls of the Current System • care tends to be reactive, episodic and hospital based; • care often initiated by patient in crisis; • division between generalists and specialists; • routine primary care can be variable; • lack of coordination between services; • relatively little emphasis on prevention and self care. 2 September 2005

11. Patients want: • to be active participants in their own care; • a personalised service, tailored to their needs, and meeting psychological as well as physical needs; • to receive services that are integrated across organisational boundaries; • easy access to high quality information; • their care to be focused on improving quality of life. 2 September 2005

12. The NHS and Social Care Model Key Strategies: • integration of services • care that is proactive, structured and systematic, matched to patient need • identification and targeting of people with complex needs • provision of high quality information and education • promotion and support for self care 2 September 2005

13. The Pyramid Model of Care Adapted from Kaiser Permanente 2 September 2005

14. Level 3: Case Management • identification of people at highest risk (case finding) • introduction of community matrons to provide high level of personalised, proactive care • structured assessment and care planning • the community matron coordinates care across all providers, and secures additional support where necessary 2 September 2005

15. Level 2: Disease Management • systematic disease management and care planning • this is a strength of the existing UK primary care system, and has been enhanced by National Service Frameworks and the new contract for General Practitioners • proactive management of disease registers • expansion of interface services - diabetes, heart failure, COPD, musculoskeletal 2 September 2005

16. Level 1: Self Care • continued development of disease specific education and rehabilitation; • expansion of the Expert Patient Programme; • mechanisms to ensure patients have appropriate disease specific and generic education, information and support; • awareness raising of the benefits and evidence for self care among clinical staff. 2 September 2005

17. US Evidence • Evercare model - 50% reduction in unplanned admissions, reduction in medication, 97% family and carer satisfaction rates • Veterans Administration - 50% reduction in bed day rates from 1994 - 1998, 35% reduction in urgent visit rates • Kaiser Permanente - significantly lower lengths of stay 2 September 2005

18. Case Management • International and national (UK) evidence confirms this approach benefits patients • Kings Fund review concludes that evidence for reducing emergency admissions is weak • no one model of case management has been shown to be superior • in the UK 2 main models are being developed, Evercare and Castlefields (Unique Care) 2 September 2005

19. Emerging Evidence - Evercare One model of case management, piloted in 9 sites, Interim Report published January 2005: • high level of patient satisfaction • effective in identifying people whose needs previously unmet • may reduce emergency admissions, but too early to quantify this • strong results in some individual Primary Care Trusts 2 September 2005

20. Emerging Evidence - Castlefields Practice-led case management, now spreading elsewhere • 15% reduction in admissions • average length of stay fell from 6.2 to 4.3 days • 41% reduction in hospital bed days used by this patient group • improved service coordination 2 September 2005

21. Expert Patient Programme Pilot Evaluation shows: • 7% reduction in GP consultations • 10% reduction in outpatient visits • 16% reduction in Accident and Emergency attendances 2 September 2005

22. Local Implementation • a Strategic Framework for Dorset and Somerset has been developed, and implementation now underway • 65 case managers will be in place by March 2007 • Challenges for us are to shift service focus from the hospital to the community, to maximise the effectiveness of primary care and to effectively embed self care 2 September 2005

23. Further Information • www.dh.gov.uk - NHS and Social Care Model • www.hsmc.ac.uk - Strategic Framework for Dorset and Somerset • www.networks.nhs.uk • www.expertpatients.nhs.uk • www.kingsfund.org.uk • www.cmsa.org - Case Management Society of America 2 September 2005