David Colin-Thomé

1. David Colin-Thomé • DH National Clinical Director for Primary Care ( clinical lead on LTC and co-chair RAG) • GP, Castlefields, Runcorn • Honorary Visiting Professor,Centre for Public Policy and Management, Manchester University • Honorary Visiting Professor, School of Health, University of Durham

2. Policy • Choice • Choosing Health • Patient Led NHS • New White Paper

3. Choice • Choice embraces three key components designed to improve people’s overall experience by providing them with more: • Power to shape their pathway through services and keep control over their lives • Preferences to choose how, when, where and what treatments they receive • Personalisedservices organised around their lifestyles

4. The health challenges & ‘Choosing Health’ WP response • Obesity • Sexual health • Mental health and well-being • Smoking • Alcohol

5. White Paper Themes • 1. my life, my choices • 2. making my life easier • 3. having my say • 4. maintaining my independenceand personal dignity • 5. the people in my life

6. CREATING A PATIENT LED NHS • the whole person – health and health services • local, convenient, modern services • new systems: choice, practice based commissioning, payment by results • more local decision making and more diversity of providers, including Foundation Trusts, role of networks • national standards, supported by inspection • COMMISSIONING

7. Commissioning • …is ‘the process by which PCTs identify the health needs of the population and make prioritised decisions to secure care to meet those needs within available resources’

8. Commissioning Primary Care • nGMS (General Medical Services) • nPMS (Personal Medical Services) • ‘Liberating the talents’ • Agenda for Change • nCommunity Pharmacy • Community Dentistry ‘Options for Change’ • Secondary to Primary care-Practitioners with Special clinical Interests, Payment By Results • Long Term Conditions- National Service Frameworks, Quality and Outcomes Framework of GP contract, Expert Patient Programme, Community Matrons( and other case managers) • ...and Practice based commissioning

9. The Registered List What use is it and should it remain? • Starfield’s work • The public’s health • Population management • Budgets for work traditionally based in hospital • -but not for purchasing • So who is managing the practice as a professionally run organisation?

10. 21st Century Primary Care • Multiple information and access points • Continuing importance of Personal Care • The potential of the registered list • Emphasis on Long Term Conditions Management including Self Management and especially of Co-morbidity • Public Health oriented Clinicians • Expanding Ambulatory Care • Quality Assured • Active in commissioning of Secondary Care • Integrated services • Choice for patients, clinicians and all staff • Increasing accountability • New forms of ownership

11. General Practice • First Contact Where Patient Chooses • Continuity of Care for Episodic Illness • Chronic Disease Management • Final Repository (“Their Doctor”)

12. Healthy Living Minor Ailment Schemes Long Term Conditions Self Care across the continuum Pure medical care ‘abdicated responsibility’ Pure self-care Individual responsibility The Self-care Continuum Daily choices Self-managedailments Chronic conditions Shared care Compulsory Psychiatric care Minor ailments Lifestyle Acute conditions Majortrauma Assisted management

13. Some self care statistics • Over-the-counter medicines sales total £2 billion a year in Britain • Two thirds ofinternet users have researched health issues online • Sales of consumer health magazines have grown at around 20% per year in the last decade • There are 1m people in England who each are providing over50 hours unpaid care per week • 50% of prescribed medicines are not used after purchase • Self-treatable disorders account for nearly 40% of GP time

14. Translation into Policy- Primary Care • Healthy Living • Choosing Health • Minor Ailments Management • New contract for community pharmacy • Long Term Conditions • LTC strategy • Self care strategy • Demand Management • nGMS, Working in Partnership Programme (WiPP)

15. LTC Management and Shared Care level 3 case management high complexity level 2 disease/care management high risk professional care level 1 self care 70-80% of CDM population self care support/ management

16. Benefits of self care Examples of evidence of beneficial effects of generic self care interventions: • hospital admissions reduced by 50% (Montgomery 1994) • outpatient visits reduced by 17% (Lorig 1985) • hospital LOS reduced (Kennedy 1990) • medication intake, e.g. steroids, reduced (Charlton 1990) • A&E visits reduce significantly (Choy et al 1999) • days off work can reduce by as much as 50% (Fries 1997) Net savings and quantifiable benefits estimated at £150 per person on a £100 spend on self care Opportunities for focusing on impacting on “downstream” delivery target areas e.g. falls affect orthopaedic demand

17. EPP An `expert patients programme’ providing lay-led self-management training courses, has proven benefits for most people with long term conditions. Early data from the Expert Patients Programme shows that there is a 7% reduction in GP appointments and 16% reduction in A&E attendance from those who attended the EPP course. The NHS Plan states that the EPP will be rolled out through the NHS by 2008 and recently additional national funding has been awarded to support this.

18. LTC • 1 in 3 people, 6 in 10 adults in England, are living with a LTC . 2/3 of those over 75 (2.64m people) are suffering from a LTC and 45% (1.2m), have more than one LTC. In the UK the General Household Survey shows that people with LTC account for around: • 80% of GP consultations • 40% of outpatient activity • 80% of hospital in-patient bed days • Costs for patients with more than one LTC are up to 6 times higher than for those with only one condition. • A growing problem • An ageing population, rising rates of obesity and more sedentary lifestyles these numbers are set to grow. By 2030 the estimate is that the numbersover 65 will more than double.

19. Chronic Disease definition & epidemiology “This places new long term demands on health care systems. Not only will chronic conditions be the leading cause of disability throughout the world by 2020; if not successfully managed they will become the most expensive problems faced by our health care system.” WHO, 2002 [1]

20. The NHS and Social Care Long Term Conditions Model Delivery System Better outcomes Infrastructure Case Management Community Resources Empowered and informed patients Decision support tools and clinical information system (CfH) Disease Management Creating Supporting Prepared and proactive health and social care teams Supported Self care Health and social system environment Promoting Better Health

21. LTC - care matched to need • Case Management • 5% of people who account for 42% of bed days • Disease Management • National Service Frameworks • Promoted in nGMS contract • Self Care • Expert Patient Programme • Also needs to spread • Promoting Better Health • Choosing Health

23. Personal health services have a relatively greater impact on severity (including death) than on incidence. As inequities in severity of health problems (including disability, death, and co-morbidity) are even greater than are inequities in incidence of health problems, appropriate health services have a major role to play in reducing inequities in health. Starfield 12/03 03-385

24. Key Principles of Case Management • Identification of patients with most complex conditions • Providing proactive care to patients with highest burdens of disease • Professional, usually clinical, case managers co-ordinating Care Plan • Working across boundaries and in partnership with secondary care clinical and social services • Care Team managing patient journey seamlessly through all parts of health and social care system

25. LTC • 50% of people with LTCs have not been told about treatment options • 25% do not have care plan • 50% do not have a self care plan • 50% medicines are not taken as intended.

26. LTC – key components of care • Population Management • Effective registers and integrated records • Evidence based ‘care pathways’ -‘Year of Care’ • Disease management and care co-ordination • Self care/self management – with information and support • Active management of at risk patients • Primary/secondary/social care co-ordination

27. Predictive power HES algorithm • For a PCT with 1500 reference admissions: • Using risk threshold of 65 – correctly predicts 74% of patients who are subsequently admitted • Using risk threshold of 80 – correctly predicts 83% of patients who are subsequently admitted • Considerably greater predictive power than other models

28. Community matrons will be nurses. The role requires a combination of clinical skills and case management skills for patients with complex needs, The community matron is a clinical role with responsibility for planning, managing and co-ordinating the care of people with complex long term conditions and high intensity needs, living in their own homes and communities. They use case management techniques to reduce unplanned hospital admissions caused by poor disease control and lack of effective prevention and support.

30. Community matron leadership • Strategic influencing • Negotiation and high degree of political astuteness • An ability to work collaboratively • Building partnership with those who provide and those who use the service