Decision details

The Board received and noted a report and presentation from Dr Ramneek Hara GP Clinical Lead and Jeremy Kidd, Deputy Director of Delivery on the work to date of the BHR CCG Long-Term Conditions (LTC) Transformation Programme led by a Transformation Board. This was established in April 2019 to develop a strategy of co-ordinated change across a range of LTC’s as detailed in the report with a view to improving quality, patient outcomes and to ensure services are delivered as efficiently as possible and integrated around the patient.

The programme of work involved identifying thematic groups with the aim of delivering a vision through two task and finish groups, beneath which are a range of sub-groups involving clinicians and officers from across the BHR system. There were also mechanisms to engage with patients and carers. 

As LTC’s had not previously constituted a defined area of work, the strategy document had been developed to understand the key challenges and the responses to such. The key challenges were seen as:

·  The gap in prevalence between national forecast levels and local levels of diagnosis, and

·  The level of activity on long term conditions in a non-elective care setting.

A clear vision for LTC’s had been developed in response to the challenges which included the development of common/single pathways for patients with multiple LTC’s, a renewed emphasis on empowering the patient to manage their own condition(s) and improving diagnosis rates.

In response to the presentation the Director of People & Resilience asked about the relationship between LTC’s and specific pieces of health work, highlighting as an example links between stress in childhood leading to LTC’s in older age. Dr Hara stated the programme had acknowledged these health links citing things like obesity, asthma, and smoking in young people with LTC’s in later life.

Reference was also made about the importance of recognising the effects for older children carers, who can ignore their own health needs and the importance of establishing support networks. There were also issues of mental wellbeing of children and young people which if not addressed could potentially lead to other health problems in later life. Overall the strategy suggested that LTC’s was an older adult problem. The CCG were advised to consider incorporating children and young people in the model.

Dr Hara then presented an overview of the Model of Care which aimed to identify people at an early stage with a range of in-scope conditions and help them to access treatment and to improve self-management of those LTC’s seen as Atrial Fibrillation, Blood Pressure, Cholesterol and Diabetes. 

He referred to the ‘Core Offer’ in the strategy involving providing the patient with information, care planning and an annual health check so as to proactively manage a condition so it does not deteriorate, and therefore decreasing the probability of multiple LTC’s occurring, for which there is a key role for Care Coordinators. It was stated that given the overall spend by the BHR CCG in respect of both planned and unplanned admissions it was estimated that long term there would be no additional financial implications arising from implementing the proposed model of care.

The Chair welcomed the model and recognised from her own experiences at the GP a real change in the way health conditions were now being managed by GP’s through taking a more holistic approach to dealing with patient needs.

Responding to the financial viability of the model Jeremy Kidd stated that the CCG had undertaken financial modelling on the volumes of spend which taking diabetes as an example showed that 85% of the allocated annual budget was spent on treating the condition and demonstrated the value and cost effectiveness of addressing LTC’s at an early stage through decreasing the prevalence gap.

The Deputy Chair explained that the model was about shifting the balance and making sure as a result of early intervention, the patient is properly sign posted to the right clinician and/or organisation, such as the GP or the voluntary sector.

It was suggested that the model did not appear to recognise respiratory health problems as an LTC, given this is a significant issue for Barking and Dagenham. The CCG acknowledged this explaining that there are planned workshops focusing on both respiratory issues and cardiology, another prevalent health condition in Barking and Dagenham. 

It was confirmed that the model was being rolled out now on a phased basis. Sharon Morrow added that the transformation programmes were in early development and acknowledged that at this stage they were NHS focussed, although the intention was to adopt a more strategic approach which would be driven forward through the Inter Care Executive Group (ICEG).