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1. An NHS and Social Care Model for improving care for people with long term conditions

Key Actions

  1. The NHS and Social Care Long Term Conditions Model will help ensure health and social care organisations take an overall structured and systematic approach to improving the care of those with long term conditions.
  2. Health and social care organisations should take action now to ensure that the model is implemented.
  3. To deliver the PSA target and have a significant impact on the way the health system works action needs to start now.
  4. The immediate focus should be the introduction of case management for the most vulnerable people with complex long term conditions.
  5. Significant numbers of hospital admissions relate to long term conditions and can be avoided.

What are we trying to achieve?

We should aim to treat patients sooner, nearer to home and earlier in the course of disease. To do this we need a combination of:

  • earlier detection;
  • good control to minimise effects of disease and reduce complications;
  • more effective medicines management;
  • reduction in the number of crises;
  • promoting independence, empowering patients and allowing them to take control of their lives, and
  • prolonging and extending the quality of life.

In summary, we want to give patients the most intensive care in the least intensive setting.

To do this we need to move away from a reactive, unplanned and episodic approach to care, particularly for those with complex conditions and high intensity needs. For example, eight of the top eleven causes of hospital admissions are long term conditions. The services are there to help them when their condition reaches crisis point, but often fail to provide the on-going, co-ordinated support needed to prevent such crises from happening in the first place.

The NHS and Social Care Long Term Conditions Model

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The NHS and Social Care Long Term Conditions Model builds on the wealth of local and international experiences and innovations, to improve the health and quality of life of those with long term conditions. (The NHS and Social Care Long Term Conditions Model reflects the wealth of experience that already exists in the NHS and among its social care partners. It draws on the 'chronic care model' researched and applied by Professor Wagner and colleagues in Seattle, USA, which shows how patients, health care providers and community organisations can interact to deliver better systems of care. It also draws on the 'pyramid of care' developed by US health provider Kaiser Permanente which identifies the population of patients with long term conditions into three distinct groups based on their degree of need.) For example, it reflects learning from US models such as Evercare and Kaiser Permanente. However, the values and structures of the NHS are different. The Model therefore also reflects the strengths of the existing infrastructures and services, particularly in primary and community care, unique to this country. The purpose of the Model is to improve the health and quality of life of those with long term conditions by providing personalised, yet systematic on-going support, based on what works best for people in NHS and social care systems.

The Model will help ensure effective joint working between all those involved in delivering care - including secondary care, ambulance trusts, social care and voluntary and community organisations - so patients experience a seamless journey through the health and social care systems.

The first priority should be to introduce a system of case management that will help those with most complex needs, help deliver the PSA target, and have the greatest impact on the way the health system works.

The Model provides a structured and consistent approach to help local health and social care partners shape the way they deliver integrated long term care locally. It details the infrastructure available to support better care for those with long term conditions as well as a delivery system designed to match support with patient need.

The levers for achieving this are empowered and informed individuals working in partnership with prepared and pro-active health and social care teams.

NHS and social care organisations are already showing how they can adapt this model to their needs. To gain the most benefit organisations will need to systematically link activity rather than work on individual initiatives. This document focuses on delivery system design.

The delivery system is the aspect of supporting people with long term conditions that most experts agree is a good place to start. Further elements of the infrastructure of the NHS and Social Care Long Term Conditions Model will be issued as supplements to this document. This will include the publication later this year of the NSF for Long Term Conditions and its supporting good practice guidance. The NSF will focus on improving services for people with long term neurological conditions but much of the guidance it offers can apply to anyone living with a long term condition.

The National Primary Care Development Team (NPDT) also highlights this systematic approach as an important lever to the delivery of improved management of long term conditions at both PCT and practice level. In particular, the work of the National Primary Care Collaborative (NPCC) has ensured that a significant number of PCTs and practices are working in a systematic way to deliver improved care for patients. The Model builds on this important principle.

Delivery system

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The recommended route to deliver a systematic approach is to utilise multi-professional teams and integrated patient pathways to ensure closer integration between health and social care. All health and social care services should begin to adopt this approach.

Different interventions should then be used for patients with different degrees of need. The NHS and Social Care Long Term Conditions Model sets out a delivery system that matches care with need.

NHS and social care organisations will be familiar with the Kaiser Permanente triangle. The Model builds on this approach.

Level 3: Case management - requires the identification of the very high intensity users of unplanned secondary care. Care for these patients is to be managed using a community matron or other professional using a case management approach, to anticipate, co-ordinate and join up health and social care. This is described in more detail in chapter 2.

Level 2: Disease-specific care management - This involves providing people who have a complex single need or multiple conditions with responsive, specialist services using multi-disciplinary teams and disease-specific protocols and pathways, such as the National Service Frameworks and Quality and Outcomes Framework. This is described in more detail in chapter 3.

Level 1: Supported self care - collaboratively helping individuals and their carers to develop the knowledge, skills and confidence to care for themselves and their condition effectively. This is described in more detail in chapter 4.

Underpinned by promoting better health - building on the public's 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, for example stopping smoking and reducing alcohol intake. Choosing Health provides invaluable guidance in this area and the new pharmacy contractual framework includes the promotion of healthy life-styles as an essential service which all pharmacies will provide.


Community resources:

Voluntary, community and patient organisations will enhance the support available locally to people and their carers. Community resources such as patient groups will also help considerably by being involved in service delivery redesign.

Decision support and clinical information systems (NPfIT):

Organisations will build on the use of evidence-based national guidelines, such as the National Service Frameworks, NICE guidance and Quality and Outcomes Framework, to be supported by local guidelines to provide standards for optimal care. Organisations need to use data, preferably held electronically, to facilitate more efficient and effective management of care through patient registers, recall and reminder systems and feedback to clinicians.

Health and social care system environment:

Organisations need to use the tools available to better organise health services. This will include 'payment by results' to move resources and the new GMS and pharmacy contracts. In addition, we would expect to see the development of pooled budgets across health and social care to build flexibility. Practice-based commissioning will bring front line clinicians into the commissioning and redesign process and the choice policy will enable patients to take greater control of their condition. Community matrons and other case managers will need to have the authority to secure services for patients at the time needed and to order investigations, make referrals and arrange admissions on behalf of patients.

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