Long Term Conditions
What did we say in Healthy Ambitions?*
1
The Long Term Conditions Pathway concentrated their work on three areas:
- Stroke
- Diabetes
- Care of older people with multiple conditions
These areas were chosen as they are areas of concern across the region – for example emergency admissions for diabetic comas were twice as high in some areas of the region compared with others.
They therefore recommended that:
- Personal care plans should be agreed annually with patients to manage their long term conditions
- The NHS should actively identify people in the community at risk from long term conditions and support them to reduce their risk of needing hospital admission
- There should be more support for people to manage their own conditions
- There should be better coordination of care between professionals and across services
- There should be better use of new technology to help self-care
- The NHS should have a greater focus on prevention of conditions such as diabetes.
Who is taking this work forward?
2
Levels of delivery
PCTs across Y&H have worked with the SHA to agree which of the recommendations of the long term conditions pathway should be taken forward locally and which might need action at regional level. This is summarised in fig.2 on the next page.
*Full details can be found at www.healthyambitions.co.uk/long_term_conditions.html.
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When is it happening?
3
The actions to be taken forward in the first year of implementation for the pathway are shown in fig.3
Local delivery
4
Working with local providers and partners, PCTs have prioritised the recommendations in Healthy Ambitions in light of the needs of their local community and the current position of their services.
They have all set out the action that they will take to start to turn the recommendations in Healthy Ambitions into reality in their five year strategic plans.
An example of the action being taken by Calderdale is shown in fig.4
An example from Calderdale PCT
The LTC programme has two ambitions
- to improve the health of those at risk of developing LTCs, by commissioning quality services aimed at prevention and early diagnosis
- to reduce mortality and morbidity for those who already have LTCs, by ensuring better access to treatment and high quality care.
How could you help?
5
Everyone with an interest in improving services can play a part in taking forward the recommendations in the Long Term Conditions chapter of Healthy Ambitions. In fig.5 we have set out some of the suggestions from staff about how people could help implement the recommendations.
As an NHS publication – this section has just focussed on the roles that NHS Staff could play – but we very much recognise that our partners have a big contribution to make if we are to deliver the recommendations of the of the long term conditions chapter in Healthy Ambitions. We know that local authorities have a big part to play – e.g. in supporting more people to live independently and in developing joint care plans and personal budgets. We are committed to working with our partners to help make this happen.
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Who will make sure that this work happens?
6
Locally
Each PCT is responsible for working with local providers and partners to ensure delivery of recommendations in line with their local priorities and their own strategic plans.
Collaboratively and regionally
Delivery will be overseen by a Pathway Delivery Board – as described in the chapter on governance arrangements.
The regional clinical leads are Eileen Burns, consultant geriatrician, Leeds Teaching Hospitals Trust and Vicky Pleydell, a North Yorkshire GP, they will offer clinical advice and leadership to the lead Chief Executive and SHA Director.
For long term conditions the chair is Ivan Ellul, Chief Executive at NHS East Riding who will act as a sponsor within the wider PCT chief executives forum and assist the clinical lead and SHA Director to promote implementation of the pathway.
How will we measure success?
7We have developed a "Healthy Ambitions Dashboard" based on a small number of key indicators which taken together can be used to start to measure the success of the Healthy Ambitions programme as a whole (see chapter on performance and metrics). This is underpinned by trajectories which each PCT will set to reflect their local priorities and circumstances and which will show the measurable improvements they are making in each pathway area. This will supplement the “vital signs” indicators and trajectories which support delivery of the targets set out in the NHS Operating Framework and the selection of outcome measures which PCTs have included in their strategic plans. In many cases these measures are one and the same. All of these measures will feature in PCTs annual operating plans to be agreed with the SHA and be the basis for the SHA’s performance management regime.
Recognising that the pathway recommendations are many and various we intend to start by tracking progress against the key pathway pledge, which for Long Term Conditions is to halve the number of preventable admissions from diabetes.
We know that this doesn’t tackle all the priorities in this chapter. Rates of hospital admissions, adults receiving individual budgets and mortality rates by a variety of long term conditions will be tracked through existing routes. The proportion of adults supported to control their condition, adults receiving individual budgets and adult with good diabetes management are already Vital Signs.
The key indicators we will therefore track in the "Healthy Ambitions Dashboard" will be:
- Admissions and readmissions from diabetes related episode
- Average length of stay for diabetic admissions and readmissions
- Percentage people with diabetes offered diabetic retinopathy screenings
- Patients with diabetes in whom the last HbA1c is 7.5 or less.
Work has been undertaken to establish baselines for the pledge and by the end of March ’09 trajectories for improvement will have been agreed between the SHA and PCTs and will be reflected in annual operational plans.* We intend to publish progress against individual trajectories.
*More details can be found in the chapter on performance and metrics.