Download Long Term Conditions - City and Hackney CCG

Long Term Conditions
PROGRAMME BOARD – CITY AND HACKNEY CCG
Examples of long term What do they have in
conditions?
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
COPD
Hypertension
Asthma
Coronary Heart Disease
Sickle cell disease
Heart Failure
Epilepsy
Atrial Fibrillation
Parkinson’s disease
Stroke
Multiple Sclerosis, Motor Neurone Disease,
other neurological conditions
Peripheral arterial disease
Chronic Kidney Disease
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
Learning
Disabilities
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 Involvement
2 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 Board
Meets 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