2. Long Term Conditions – development of the current agenda and role of data analysis Dr. Peter Cansfield East Midlands Public Health Observatory

3. National Information 60% of adults have a long term or chronic health problem Up to 80% of GP consultations are with people with a long term condition (LTC) Mostly minor conditions, but 5% of patients with LTC account for 42% of hospital bed days

5. What are LTCs? N.B. Pyramid is not Egyptian

6. New care models Evercare Kaiser permente Unique Care / Castlefield Eldercare Etc… community matrons / managers, personalised care management

7. Evercare Nurse-led – Advanced Practitioner Nurses Good use of data and information Identification of at risk population Virtual integration managed by APNs

8. Kaiser Permente Integration Active case / care management Self care / management Clinical Leadership Data and information

9. Drivers and Targets Drivers – Improved care – Financial (PBR and unplanned admissions) Targets – Community matrons – centrally determined number for each health community – Reduce emergency admissions by 5% by 2008

10. How can we predict which patients are ‘frequent fliers’? United Health Care – Jean Kings Fund – Howard Dr. Foster – Steve Local (e.g. Risk factor – Eldercare) – Hanna

11. Questions Which risk assessment tool and why? What is the strength of evidence to support one method over another? Models and the data required – a pragmatic trade-off? Data access: How internal restrictions on data overcome? Other practical difficulties? Value: should we take a view?