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Years of this…
2000 – 2050: The Legacy
Rising at all ages…People reporting a chronic condition (by age)
0
10
20
30
40
50
60
70
80
1972 1975 1981 1985 1991 1995 1996 1998 1998 2000 2001 2002
Year (note: data from1998 is w eighted)
% o
f sam
ple
0-4y
5-15y
16-44y
45-64y
65-74y
75+
Implications of aging population
• More likely to live alone• More likely to have functional
dependency and sensory impairment• More likely to have long term condition• More likely to have co-morbidity• More likely to have cognitive impairment
• More likely to have multiple medications • More likely to develop complications of
acute illness• More likely to develop infection• More likely to stay longer in hospital• More likely to require rehabilitation
Long Term Condition
“Condition that requires ongoing medical care, limits what one can do, and is likely
to last longer than one year.”NHS Scotland 2005
Healthcare Burden of LTCs
People with LTCs contribute ….
• 80% of all GP consultations • 60% of all inpatient bed days• 70% of all emergency admissions • 80% of all prescribed medicines • 50% of people with LTCs do not take prescribed
medications• Economic and Social aspect
Impacts on whole system
By 2030 incidence of LTCs in the over 65s will have doubled
Key points….
• 5% of people occupying acute hospital beds accounted for 43% of bed days
• Most deprived are twice as likely to be admitted than least deprived
• People in the high use group have multiple diagnoses ( four or more)
An example…….• Heart failure
– Expected to rise by 40% over the next 20 years
• Diabetes – 1.3 million with another million undiagnosed
• Peripheral vascular disease– 4.5% of people between 55 – 74 show signs of PVD
• Respiratory disease– COPD 600,000– Asthma 3.7 million adults & 1.5 million children
Current systems……Medical model still
existsSystem is not
seamless
Too many “hand offs”
Lack of co-ordination
People lost during transitions
Change is essential
Poor communication
Need continuity
Lack of information
Inequity of care
Other concerns……• Carers issues• Transition from child services to
adult care and older adult• Non-adherence / concordance• Impact on family
LTCs - Was the organisation ready?
• Self Assessment Tool kit (SGHD)• Long Term Conditions Action Team• Organisation of Long Term Conditions
– CHPs – Responsibility– Board & Management Support– Links with right people / agencies / organisations– Shared objectives (Primary & Secondary Care)– Links with & informed Community Planning
Standards…..
• Patient Information & supported self care• Service redesign - must include LTC• Multi-agency working• Interdisciplinary education and training• Information and Intelligence• Quality and Delivery• Set up Long Term Conditions Action Team
Long Term Conditions Collaborative
• Collaborative methodology• LTCAT = LTCC Programme Board• Wide stakeholder membership• National and Regional Team• National Improvement Measures• 4 Workstreams
Self Management• Diabetes• COPD• Pain• Stroke• Generic Exercise Project• Self Held Care Plans• Directory of Services• Carer support & training• Clinician support & training
COPD Self Management
First Hand Experience
Condition Management
• MCNs Clinical pathways• CSIGs Clinical & Service Models• Optimising roles• Clinical support & training• Carer support & training• Neurology
Complex Care
• Integrated Care Management• Care Homes Support• Palliative Care (malignant & non
malignant)• Anticipatory Care Plans• Community Hospitals
Information & Evaluation
• National improvement measures• Local improvement measures• Logic Model approach
LTCCP & New Horizons
• LTCCP improvement actions/developments
• New Horizons actions/deliverables
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