Long Term ConditionsPROGRAMME BOARD – CITY AND HACKNEY CCG

Examples of long term conditions?

What do they have in common?

What is a long term condition?“A Long Term Condition is defined as a condition that cannot, at present be cured; but can be controlled by medication and other therapies. Examples of Long Term Conditions are diabetes, heart disease and chronic obstructive pulmonary disease.

There are 15.4 million people living with a long-term condition in England. Numbers are expected to rise due to an aging population and unhealthy lifestyle choices”.

Department of Health

In City and Hackney we have approximately 70,000 people with a long term condition

Why does it matter?Living with a long-term condition can have wide ranging impacts including:

family roles

relationships

ability to work

education

accommodation

finance

and others….

Which conditions do we cover?Diabetes

Hypertension

Coronary Heart Disease

Heart Failure

Atrial Fibrillation

Stroke

Peripheral arterial disease

Chronic Kidney Disease

COPD

Asthma

Sickle cell disease

Epilepsy

Parkinson’s disease

Multiple Sclerosis, Motor Neurone Disease, other neurological conditions

Learning Disabilities

Cross over with other boards e.g. depression / dementia / cancer

Clinical leads and sub-boards…..Area Clinical Lead Meetings

Diabetes Dr. Kathleen Wenaden Diabetes Ops and Local Strategic Advisory Group (each 3X / year)

Cardiac and stroke Dr. Chris Carvalho Cardiac LIT and stroke board each 3X /year

Respiratory Dr. Meena Krishnamurthy Respiratory board 3X /year

LearningDisabilities

Vacant Regular joint LD commissioning board (with LBH)bi-monthly

Sickle Cell Dr. Jenny Darkwah Regular commissioner / provider meetings

Social Prescribing Dr. Patrick Hutt Steering group quarterly

Renal New area – being covered by Dr. Clare Highton

Steering group set up

Overall clinical lead for LTC board is Dr. Clare Highton

Patient and Public Involvement2 PPI reps on the LTC board with a wide range of experience and skills between them

Consultation with PPI committee on specific plans such as commissioning intentions or service specification

Wider consultation with members of the public e.g. Commissioning intentions event

Consultation on specific issues with specific groups e.g. stroke unit review

Work with Healthwatch e.g. sickle cell

LTC Board – overall aim

“To help people with long term conditions feel more supported to manage their own condition”

Why?

Because…..People with long term conditions account for:

50% of all GP appointments

64% of outpatient appointments

70% of all inpatient bed days

In total, around 70% of the total health and care spend in England is attributed to caring for people with long term conditions

This means that 30% of the population account for 70% of the spend

More importantly….. It improves quality of life and reduces complications of disease and ill health

Patient.co.uk say:

“Research suggests that the people who do best are those who take responsibility for managing their own long-term condition in partnership with their doctors”

How do we work towards our aim? Long Term Conditions locally enhanced service – ask GPs in City and Hackney to carry out a range of activities to provide additional support to people with long term conditions such as:Case finding

Annual reviews / health checks

Controlling risk factors such as blood pressure and high cholesterol – very important in extending years of healthy life and preventing complications of disease

Additional consultation time for people with multiple problems

Referring to services such as smoking cessation and exercise on referral

Commissioning support services such as TLC stroke care, Ability Bow, community heart failure nursing and Acute COPD Early Response Service (ACERS)

Commissioning a “step-down” unit for people with brain injury to transition from a hospital environment to home by learning more community skills and independence in daily living

How do we work towards our aim? (2)Non-recurrent funding and innovation grants such as Epilepsy Society – self-management course

Additional support for sickle cell team – psychology, social care liaison, and a 24 hour telephone helpline

Additional resources for the diabetes team to help people with foot problems, young adults with diabetes and people not engaging with health care

Funding training for local health care staff to learn how to deliver the Certificate in Diabetes Care training course to other local staff

An Asthma specialist nurse working with patients with brittle asthma at high risk of hospital admission

Cardiac rehabilitation in the community and a new rapid access service for people with Atrial Fibrillation

Long Term Conditions Programme BoardMeets every other month including clinical leads, patient representatives, hospital representatives, Public Health (London Borough of Hackney), finance, prescribing, and outcomes lead

Receives reports from sub-boards on their work

Reviews bids for non-recurrent funding; audits in clinical areas; national guidelines such as NICE; service specifications and performance metrics; budget review; risk register; conflicts of interest

Presentations on research or locally applicable services

Partnership working Across programme boards e.g. prescribing, Mental Health and planned care

We work closely with colleagues in the London Borough of Hackney on Public Health issues (prevention of disease and healthy lifestyles), Learning Disabilities, Continuing Health Care for people requiring ongoing care from the NHS and social prescribing

Voluntary sector organisations including HCVS; Sickle Cell Society, Epilepsy society; TLC stroke services, Ability Bow and others