Improving clinical outcomes and supporting patients living with chronic Long Term Conditions.

Long Term Conditions have become a major focus of the Department of Health and a cross-government long-term conditions strategy is being developed.

The shared goals of this are:

1. People are supported to stay healthy and avoid developing a long-term condition where possible.

2. People have their conditions diagnosed early and quickly.

3. Services are joined up and based around individuals’ biological, physiological and social needs.

4. People with long-term conditions are socially included, including succeeding at work and education.

5. People with long-term conditions are as independent as possible and in control of their lives (up to and including the end of life).

People with long-term conditions are supported to stay as well as possible.

Following a Stakeholder event on 14 and 15 March 2012: the Department of Health published the 3rd edition of the Long Term Conditions Compendium of Information on 30 March:

“There are around 15million people living with a long-term condition in England. These people are the main driver of cost and activity in the NHS as they account for around 70% of overall health and care spend. They are disproportionately higher users of health services representing: 

50% of GP appointments

60% of outpatient appointments

60% of A&E attendances

70% of inpatient bed days

The LTC QIPP workstream seeks to improve clinical outcomes and experience for patients with long-term conditions in England. The work stream will focus on improving the quality and productivity of services for these patients and their carers so they can access higher quality, local, comprehensive community and primary care. This will, in turn, slow disease progression and reduce the need for unscheduled acute admissions by supporting people to understand and manage their own conditions.

A reference panel agreed a model of cares for LTCs based on the 3 key principles (risk profiling, integrated care and self care), which are the fundamental features of all best-practice LTC care programmes both here and abroad. The fourth element in this process is the need to implement them ALL.

The workstream seeks to reduce unscheduled hospital admissions by 20%, reduce length of stay by 25% and maximise the number of people controlling their own health through the use of supported care planning. The workstream aims to replicate this performance nationally by 2013-14.” Sir John Oldham (June 2011)

Focusing on these QIPP objectives, LTC interface has produced multiple chronic disease management plans, enabling patients and carers to be empowered by education and choices, and chronic disease management guides to help healthcare professionals to revolutionise patient care.

Bespoke guides for each long-term condition can be produced, containing a regional focus to further enhance local integrated care.

• Local Guidelines

• Local Contacts

• Local Formulary

• Local Prescribing Analysis

• Local QIPP Project Analysis

• Local Performance Tracking

• National Guidelines