Royal College of Nursing

Dr Marina Lupari

Professional Lead for Primary &

Community Care

Improving functional ability in

people with long-term

conditions

Enhancing the life of people living with long-

term conditions and supporting people into

employment.

Metrics in the NHS Outcomes

Health related quality of life for people

with long-term conditions;

Proportion of people feeling supported

to manage their condition and;

Employment of people with long-term

conditions.

Update on employment metric…..

It is estimated that around one quarter of working age adults have one or more long-term conditions, and employment rates for this group are around 60% -typically 10-15% lower than for the general population.

Trends in employment in the general population showed a fall between 2007 and 2010, whereas employment of people with LTCs was broadly steady. This resulted in a narrowing of the gap between the two rates (from 15% in 2006 to 11% in 2010).

From mid-2012 employment in the general population began to increase - a rise not reflected in employment rates for those with long-term conditions. This resulted to an increase in the gap between the rates to 14% at 2013/14 Q3.

Chronic Obstructive

Pulmonary Disease

AsthmaCoronary Heart Disease

Diabetes

HIV/Aids

Spinal Cord Injury

Sickle Cell Disease

Stroke

Obesity

Epilepsy

Cancer

Parkinson’s

Skin Disease

Dementia/Alzheimer’sDepression

SchizophreniaBi-Polar

5.5

Arthritis Multiple Sclerosis

What do you mean…LTC?

Living with a LTC

5.8

For many people, being diagnosed and given a label of a

long term condition means hearing there will be things they

can no longer do

Long term conditions bring challenges that the person will

have to face -

Day to day activities they may be limited in

Equipments they may come to rely on

Using support services to remain in their own homes

Life-long medication they must take

Physical changes to their bodies

Periods of emotional distress

This impacts significantly on employment

Strategy …In a nutshell…

The Problem

The successful management of long-term conditions is now

- and will remain - a key objective of the NHS

The Theory

We all know in theory that primary care/community

is an under-utilised setting which should have a

major role to play in the management of LTCs (cost

effective, skilled, patients like it, located in all

communities)… but HOW?

The AnswerThis presentation describes shows how primary care /

community approaches can realise the potential of LTC

care and enhance employment opportunities, and knit it

into a comprehensive and coordinated package of care for

people with long-term conditions.

The context

Successful management of long term conditions

underpins the achievement of NHS reforms:

It is about:

– Timely and accurate diagnosis

– Treatment standards based on best evidence

– Empowering patients to be partners in their care

– Developing capacity in primary care and shifting

work from secondary care

Infrastructure

Health and social

system environment

Decision support

tools and Clinical

information system

(NPfIT)

Community

Resources

Delivery System

Disease

Management

Case Management

Better outcomes

Prepared and

proactive health and

social care teams

Empowered and

informed patients

Supported

Self care

Promoting Better

Health

Su

pp

ort

ing

Cre

ati

ng

The NHS and Social Care

Long-Term Conditions Model

The CCH Integrated Model

10

Key tenet of care……

“ Personalised care and more self-

care in an integrated way…more

services in local communities that are

closer to people’s homes and more

emphasis on prevention”.

Lord Warner, June 2006

• ‘not a passive victim of illness’

• A decision maker

• A care manager

• A co-producer of health

• An evaluator of quality

• An active citizen, voter & taxpayer

(Source: The Autonomous Patient –Angela Coulter)

Changing public expectations

Statements

• The person with a long term condition is in charge of their own life and managing their condition(s)

• The person with a long term condition is the main decision-maker in terms of how they live with and manage their condition(s)

• The person with a long term condition is more likely to act upon the decisions they make themselves rather than those made for them by a professional

• The person with a long term condition and the health care professional are equals and experts

The Year of Care Consultation Skills and Philosophy Toolkit © Year of Care v7 08/07/10

http://www.diabetes.nhs.uk/year_of_care

14

Engaged,

informed

individuals

& carers

Commissioning

Organisational

& clinical processes

Person-

centred,

coordinated

care

Health & care

professionals

committed to

partnership

working

Plan

Study

Do

Act

The House of Care:

The House of Care describes four key interdependent components that, if

implemented together, will achieve patient centred, coordinated service for

people living with long term conditions and their carers.

Organisational and Clinical Processes

Person centred-

coordinated

care

Health and Care

Professionals

committed to

partnership

working

• Integration

• Culture

• Workforce

• Technology

• Care Co-ordination

• Care Planning

• Information and technology

• Care Planning

• Safety and Experience

Informed and

engaged patients

and carers

• Self management

• Information and

Technology

• Group and peer

support

• Care Planning

• Carers

Commissioning • Service User and Public Involvement

• Contracting and procurement

• Needs Assessment and Planning

• Joint commissioning of services

• Metrics and Evaluation

• Care Planning

• Tools and levers

Build my own

house

• Guidelines, evidence and

national audits

• Care Delivery

Health systems of the future: Will they support LTC care?

Support for the General practitioner…

• Framing clinical problems from the patient’s perspective

• Avoiding tendencies toward situational control, selective inattention, and over-learning

• Acknowledging uncertainty, instability, uniqueness, and value conflict

…navigating in complex adaptive systems

• Simple rules

– Direction setting

– Boundaries and limits

– Incentives and rewards

• Integrating decision support

• Measuring and celebrating improvement in decision quality

Practice nurses and Community nurses have great

potential to contribute to this agenda…And the

more experienced they become…

The role of clinical nurse

specialists

We view with concern reports of apparent

downgrading of the role of, and reductions

in the numbers of, specialist nurses. Their

expertise is vital in supporting an

integrated system of care for diabetes,

from self-management through to acute

and specialist services. (Paragraph 81)

DoH (2014) Government Response to House of

Commons Health Select Committee Report into LTCs

Self care educational interventions

Educate the clinician or the patient?

Group or individual patient education?

Brief or long intervention?

Reinforcement?

Disease specific or generic education?

Theory based (which one?) or

atheoretical?

Taught by professionals or lay people?

Educating patients: Heart Manual

Trained facilitators, six weekly group sessions

Empowerment approach

Home exercise programme

Relaxation and stress management

Identification of aberrant beliefs and behaviour

– Mental health - Significant improvements in GHQ

scores

– Hospitalisation – more than halved in first 6m

– GP visits – 20% reductions over first year

Educating patients:

group education for diabetes

11 trials, 1532 patients – at 1 year:

– HbA1 improvement of 0.8%

– Fasting blood sugar reduced by 1.2mmol

– Reduced weight of 1.2Kg

– Knowledge improved

– Systolic blood pressure reduced 5 mmHg

– Reduced need for oral hypoglycaemics

NNT=5

EPP vision of success:

• Disease process slowed

• Better symptom and medicine

control

• Better health status

• Reduced health care use – 40%

• More appropriate health care use

• Evaluation not a feature

Summary

Key features of successful programmes

are:

– Empowerment approach

– Addressing erroneous health beliefs

– Clinical disease management skills

– Teaching coping skills

– Addressing psychological aspects

Back to the root cause…..

Demographics and the rapid increase in chronic disease

2002

10 million

Japan

USA

Western Europe

2025

100 million

33 million

72 million

90 million

Numbers of People Over 65

Source: US Bureau of Statistics

• Changed & poor diet

• Less physical activity

• Poor lifestyle choices

• Obesity

• Cardiovascular disease

• Type 2 diabetes

There are three kinds of people:

Those who watch things happen

Those who wonder what happened

Those who make things happen

Which one are you?