Jan Hull Acting Director of Development Services for People with Long Term Conditions: Policy and Models of Care in the United Kingdom Jan Hull Acting Director of Development

Long Term Conditions the UK health system NHS policy for long term conditions delivering improved services: the proposed model emerging evidence on the new approaches local implementation. 2 September 2005 10 February 2005

The UK Health System 2 September 2005

Dorset and Somerset Strategic Health Authority Counties of Dorset and Somerset Combined population of 1.2 million Approximately 26,000 NHS employees 1,094 GPs in 178 Practices 25 Community Hospitals NHS expenditure of approximately £1.25 billion A small to medium sized SHA – one of 28 in England NHS is world’s second largets employer. With more than 1 million staff, one in 25 (approx) of working adults are employed or contracted by the NHS. The odds are that at least a few of you are related to an NHS employee 2 September 2005 10 February 2005

Long Term Conditions The WHO definition includes: non- communicable conditions persistent communicable conditions long term mental disorders ongoing physical/structural impairments 2 September 2005

The Challenge Optimal management of chronic disease is one of the most complex and potentially costly challenges facing modern healthcare systems 78% of healthcare spending (US data) WHO estimates 75% of global population living with one condition, 50% with 2 or more In the UK people with long term conditions use 60% of hospital bed days 2 September 2005

Increasing Policy Focus burden of ill health and disability increasing prevalence of long term conditions and related risk factors high utilisation of services, particularly through unplanned admissions, by people with multiple conditions learning from international models of care 2 September 2005

NHS Policy Context Transforming services for people with long term conditions is now a central element of NHS policy This commitment is set out in The NHS Improvement Plan (2003) and the current 3 year Planning Framework, ‘National Standards, Local Action’ The model for delivering improved services ‘Supporting People with Long Term Conditions: An NHS and Social Care Model to support local innovation and integration’ was published in January 2005 2 September 2005

Emergency Bed Day Targets national target of 5% reduction in emergency bed days by 2008 has been set for Dorset and Somerset this equates to 36,000 bed days (baseline 858,000 emergency bed days in 2003/04) 2 September 2005

Shortfalls of the Current System care tends to be reactive, episodic and hospital based; care often initiated by patient in crisis; division between generalists and specialists; routine primary care can be variable; lack of coordination between services; relatively little emphasis on prevention and self care. 2 September 2005

Patients want: to be active participants in their own care; a personalised service, tailored to their needs, and meeting psychological as well as physical needs; to receive services that are integrated across organisational boundaries; easy access to high quality information; their care to be focused on improving quality of life. 2 September 2005

The NHS and Social Care Model Key Strategies: integration of services care that is proactive, structured and systematic, matched to patient need identification and targeting of people with complex needs provision of high quality information and education promotion and support for self care 2 September 2005

The Pyramid Model of Care Adapted from Kaiser Permanente 2 September 2005

Level 3: Case Management identification of people at highest risk (case finding) introduction of community matrons to provide high level of personalised, proactive care structured assessment and care planning the community matron coordinates care across all providers, and secures additional support where necessary 2 September 2005

Level 2: Disease Management systematic disease management and care planning this is a strength of the existing UK primary care system, and has been enhanced by National Service Frameworks and the new contract for General Practitioners proactive management of disease registers expansion of interface services - diabetes, heart failure, COPD, musculoskeletal 2 September 2005

Level 1: Self Care continued development of disease specific education and rehabilitation; expansion of the Expert Patient Programme; mechanisms to ensure patients have appropriate disease specific and generic education, information and support; awareness raising of the benefits and evidence for self care among clinical staff. 2 September 2005

US Evidence Evercare model - 50% reduction in unplanned admissions, reduction in medication, 97% family and carer satisfaction rates Veterans Administration - 50% reduction in bed day rates from 1994 - 1998, 35% reduction in urgent visit rates Kaiser Permanente - significantly lower lengths of stay 2 September 2005

Case Management International and national (UK) evidence confirms this approach benefits patients Kings Fund review concludes that evidence for reducing emergency admissions is weak no one model of case management has been shown to be superior in the UK 2 main models are being developed, Evercare and Castlefields (Unique Care) 2 September 2005

Emerging Evidence - Evercare One model of case management, piloted in 9 sites, Interim Report published January 2005: high level of patient satisfaction effective in identifying people whose needs previously unmet may reduce emergency admissions, but too early to quantify this strong results in some individual Primary Care Trusts 2 September 2005

Emerging Evidence - Castlefields Practice-led case management, now spreading elsewhere 15% reduction in admissions average length of stay fell from 6.2 to 4.3 days 41% reduction in hospital bed days used by this patient group improved service coordination 2 September 2005

Expert Patient Programme Pilot Evaluation shows: 7% reduction in GP consultations 10% reduction in outpatient visits 16% reduction in Accident and Emergency attendances 2 September 2005

Local Implementation a Strategic Framework for Dorset and Somerset has been developed, and implementation now underway 65 case managers will be in place by March 2007 Challenges for us are to shift service focus from the hospital to the community, to maximise the effectiveness of primary care and to effectively embed self care 2 September 2005

Further Information www.dh.gov.uk - NHS and Social Care Model www.hsmc.ac.uk - Strategic Framework for Dorset and Somerset www.networks.nhs.uk www.expertpatients.nhs.uk www.kingsfund.org.uk www.cmsa.org - Case Management Society of America 2 September 2005