LTC0011 - Evidence on Management of long-term conditions

Final 2: January 2013

Delivering better services for people with long term conditions (LTC)

– getting on with it!

The aim of the current initiative is to bring together all the expertise across the ‘LTC Landscape’ (a coalition of the willing) around a Delivery System as a starting point for comprehensive change; led by the people involved (service users, policy makers, academics, practitioners, Colleges, trainers, service providers etc) and offering those ‘on high’ a chance to help to make it happen more easily.

Back ground

Chronic diseases are now the commonest cause of death and disability in England and people who live with long term conditions (LTCs) are the biggest uses of services and greatest generator of costs. It is now recognised that the care and support needed to live with a LTC is fundamentally different to that for acute episodic conditions, and that this will require services for people with long-term conditions to be radically redesigned. However, despite exhortation from people who live with LTCs, consistent health policy, a robust evidence base and a compelling economic case, progress on the ground has been painfully slow with little improvement over the last 10 years.

Many of the elements needed to support change in England have been developed, drawing on international best practice, but they remain fragmented. Top down exhortation and targets have failed to influence change and clinical behaviour at the grassroots. The missing component, which is a practical, robust, reproducible and transferable delivery system developed by practitioners and service users in England is now available.

Key issues

The Delivery System is described below. Some of the key issues it addresses include:

People who live with long term conditions are central to the process. They are involved in articulating their own needs and deciding on their own priorities, supported by health and social care professionals through a process of information sharing, shared decision making and action planning.
Support self management (SSM) and the development of partnership relationships between people who live with LTCs and health care professionals is at the heart of service delivery. This shifts the focus onto the roles and responsibilities of both, and the systems that are needed to support them. The ultimate aim is that people should have the knowledge, skills and confidence to manage their condition effectively in the context of their everyday life.
The Delivery System can help to reduce inequalities. The number of LTCs and their burden falls disproportionately on those with poor health literacy and in lower socioeconomic groups. Tools, skills training and ongoing support in a variety of formats are available to identify both those who find it harder to engage with health issues (low levels of ‘activation’) for whatever reason, and who will who need extra support.
The Delivery System not only brings together well planned and coordinated specialist support but is based on a generic approach. This ensures that each individual is involved in a single, holistic care planning process with a single care plan. The common set of relevant skills and processes involved also reduces the burden of training.
Quality assurance of the philosophy, core approach and skills is essential to ensure that implementation both builds on relevant evidence and experiential knowledge and ensures that the intervention is delivered consistently increasing the likelihood that it will lead to the impact expected. ‘While the case for SSM is strong not all reported SSM interventions are effective.’
Care planning is the gateway to personalisation and/or personal health budgets.

The coordinated delivery system for Long terms conditions

The delivery system provides a robust, systematic and reproducible approach, transferable to any setting and for people with any single or multiple LTCs, including multi morbidity which ensures that each person receives a uniquely personalised service bringing together support for self management with high quality clinical and social care, delivered in a systematic, coordinated and high quality manner.

The two part delivery system includes a guide to the components and a quality assured approach to implementation

The components

A collaborative care planning consultation for everyone including shared decision-making, which brings together the individual’s and the professional’s perspectives (agendas) and expertise, encompasses all the individual’s health issues and supports the individual to identify their own information needs, goals and action plans.
Access to a range of local services people need to support the goals and actions they identify, including social prescribing [1]
Coordination of any additional clinical and social input / support required from integrated multidisciplinary teams

Care planning

Care planning is a proactive intervention with the frequency of care planning consultations being determined by the interaction between systematic interrogation of practice and disease registers (‘population risk stratification’), and individual needs (agenda) identified in dialogue between the person, the health professional and relevant carers. The frequency, style, intensity, place, person and finances for follow up (in intervals between care planning consultations) are determined during the care planning process itself.

Individual care planning is a three step process of preparation ( reflection by the individual on relevant test results and/or prompts – collation of health issues by the professional), the consultation itself (identifying information needs, goals and action plans, and explicit arrangements for follow up), with summarising and recording
This usually cannot be carried out without changes to the culture and infrastructure of care, thus driving change.
The Year of Care ‘House’ model describes the issues which each team will need to address to make care planning possible.

Implementation

The delivery system invites local services to work through the ‘house’ for the particular health / social care setting relevant to their particular population, ensuring that attitudes, skills and infrastructure are all addressed together by using a quality assured approach leading to culture and system change. Importantly, the care planning consultation is in the centre of the house; local services need to ensure that all of the elements of the house are reliably in place for every care planning consultation.

This will involve:

Acknowledging the philosophy and principles of systematic support for self management (the driver of the delivery system)
Identifying accountable leadership
Identifying the population involved (‘risk stratification’)
Identifying the capacity of individuals to engage in the processes; supporting them to do so

Identifying the multidisciplinary/ integrated delivery teams involved and the roles and responsibilities of team members in order to ensure that care is co-ordinated
Using available evidence-based and quality assured interventions
Identifying metrics, methods of collection, analysis and feedback; to drive improvement

Alf Collins, Simon Eaton, Jim Phillips, Sue Roberts: with thanks to all those who have contributed

[1] Social prescribing is an ‘unfortunate’ term in common use for referral to non traditional community services to support self management such as exercise ‘on prescription’.