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White Paper pilots: whole system long term conditions (LTC) demonstrator programme

  • Last modified date:
    28 September 2007
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Update - 28 September 2007

After the successful selection of the three Whole System Demonstration sites in May 2007 (Newham, Kent and Cornwall), the DH programme team are working with the sites, their delivery partners, project management partners and our evaluation consortia to develop the detailed implementation plans. 

Planning activity on each site is covering key delivery areas; governance arrangements and roles and responsibilities, identifying target population, baselining evaluation criteria, procurement of assistive technology, communications and engagement of stakeholders, assessment and care planning, developing integrated teams, developing pathways and assistive technology referral and response protocols, rolling out new pathways and aligned assistive technology deployment, integrating NHS and LA data sets, and capturing learning from this programme.

Robust and rigorous programme management practices are being employed at each site and centrally, in order that documentation records all the planning and implementation steps of the programme and captures learning and best practice to inform wider roll out for the future.

Update - 23 May 2007

The Department published proposals within the White Paper, 'Our health, our care, our say:  a new direction for community services', to establish Whole System Demonstrators that will test the benefits of integrated care supported by advanced assistive technology.

The selection process for the Demonstrators has now concluded and the three successful sites were announced in a press release on Wednesday 23 May.  The successful NHS/LA partnerships are confirmed as Cornwall, Kent and Newham.

The demonstrators will support individuals with longer-term and complex health and social care needs through the creation of multidisciplinary teams at PCT and local authority level.  The teams will develop integrated care plans, and where appropriate, advanced assistive technology will be deployed in the home to support the provision of care.  The aim of the demonstrators will be to show that we can help people with more complex needs maintain their independence, achieve significant gains in quality of life and reduce unnecessary acute hospital and care home use.

The competition to select the Demonstrator sites was launched on the 21st December 2006 via the DH Chief Executive Bulletin.  NHS/LA partnerships were invited to submit initial expressions of interest by 22nd January and following this, full proposals were received by the 22nd of February.

A number of full expressions of interest were received from NHS/LA partnerships across the country.  The proposals were very detailed, of a high quality and covered all of the conditions and patient groups we mandated within the application prospectus.

The announcement of the successful sites, follows an extensive and robust assessment period, involving a team consisting of representatives from across the Department of Health’s internal delivery partners.  The successful sites represent a balanced portfolio in terms of the criteria we expected the Demonstrators to fulfill.

Following the announcement, the Department will now work with the successful sites to finalise detailed implementation plans with the sites going live from summer 2007.

Introduction and overview - November/December 2006

The White Paper 'Our health, our care, our say:  a new direction for community services' set out a new direction for the whole health and social care system. There will be a radical and sustained shift in the way in which services are delivered, ensuring that they are more personalised and that they fit into people's busy lives.

The vision for community-based care

The 'Our health, our care, our say: making it happen' report published 18th October 2006 provides an update on progress on implementation to date against those goals, and a brief forward look to the next stages. The shift in the way services are delivered is necessary not only because it responds to what people want, but also because the needs of today's and tomorrow's users of health and social care services are very different from those of yesterday.  Local services are central to supporting independence and quality of life for the growing numbers of people with long-term needs, for whom care begins in the home.

To deliver this vision of community-based care, we need to see a significant change in the way care is delivered, away from the 'one size fits all' approach of reactive care, often delivered in a hospital setting to a person-centred, responsive, adaptable, flexible service. We also need to take full advantage of the exciting new possibilities opened up by electronic assistive technologies.

There is now reliable international evidence, supported by small scale pilots in this country that significant improvements in the health and well-being of those with complex long term conditions can be achieved through comprehensive care approaches.  Our challenge is to demonstrate that such significant shifts from hospital care are possible on a wider scale and that more people can be supported to retain their independence in the community.  By providing integrated approaches with a strong focus on helping people to help themselves and the use of remote health and care technologies, we need to provide credible evidence that it will benefit the individual and the quality of life of carers, as well as delivering gains in both clinical and cost-effectiveness of care.

Delivering this whole system approach to care and support

For people with complex long term health and social care needs, we plan to bring together knowledge of what works internationally, with a powerful commitment to new, electronic assistive technologies to demonstrate major improvements in care and support. This will include:

a strong emphasis on patient education and empowerment
 comprehensive and integrated packages of personalised health and social care services
joint health and social care teams, 24/7 contact and an information system that supports a shared health and social care record
good local community health and care facilities
health and social care commissioners with the right incentives to deliver better care for those with complex needs
mandatory risk stratification to identify those most at risk, and
intensive use of assistive and remote monitoring technologies.

Benefits of the whole system integrated care approach

The White Paper Whole System LTC Demonstrators will deliver care that:

promotes individuals' long term independence
improves individuals' and their carer's quality of life
improves the working lives of staff
is more cost effective
is more clinically effective
addresses diversity and equality issues and
provides an evidence base for future service design and care reform.

The pilot sites

We will ensure that the total resident population covered is at least one million and from a variety of demographic and geographical contexts. It is anticipated that there will be up to three pilots. This will ensure that we can pilot in areas with different health and social care configurations.

The pilots will run for a minimum of two years and will be subject to a rigorous 'real time' evaluation process.  The pilots will be on a scale significantly greater than anything undertaken in England to date; in the region of several thousand telehealth and telecare installations over the two year period across all of the sites.

Application process

We will, in due course, invite detailed applications for involvement in the White Paper Whole System LTC Demonstrators from local authority/NHS led partnerships. We recognise that for an NHS/LA partnership to pull together such an application it will involve working with a number of NHS, social care, private, voluntary and charity sector partners.  We have therefore set out the likely key elements that will inform an application at Annex A.  There will also need to be some early consideration of ethical, governance and operational protocols to support this programme. This takes time and effort and so we are giving advance notice of the programme so that interested parties can start to liaise and scope how they might deliver a White Paper Whole System LTC Demonstration Site. 

Supporting technology

The technology employed by the pilots will need to be a mix of telecare, telehealth and information integration. Pilots will need to demonstrate that installations are in areas and populations where they can make a significant difference to health and social care outcomes.  To reduce the burden of procurement and provide true value for money, organisations will be able to use the new Telecare National Framework Agreement to source potential suppliers of telehealth and telecare equipment, together with monitoring and response options.  NHS PASA have negotiated the Agreement with fifteen suppliers and will provide support to the pilots in achieving the optimum procurement outcomes.

The target patient/user groups

We are planning to focus on two main patient/user groups. Work on both groups will be mandatory for each pilot:

  • people of any age who are at risk of current or future hospital admission, due to at least one of the following conditions: chronic heart disease, chronic obstructive pulmonary disease (COPD) or type 2 diabetes.
  • the frail elderly who are at risk of current or future hospital admission, who have complex health and social care needs. They may have one or more of the above conditions.

Further detailed information and guidance on the White Paper Whole System LTC Demonstrator programme will be provided in the near future.  This will include a prospectus with timetable and application form. Please email further queries relating to this programme to: 

NHS PASA (NHS Purchasing and Supply Agency) National Framework Agreement for Telecare (NFA)

The Department of Health recently supported the NHS PASA Telecare NFA awareness days held in London on 14 November and in Leeds on 23 November.  The NHS PASA website provides more information about the NFA and also copies of the presentations given at the recent awareness days.  The site can be visited at:

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