Framework for managing long term conditions The Plymouth PCT commissioning approach

Plymouth approach Accept that long term conditions is a huge subject – almost unmanageable It cuts across emergency and elective care Impacts on nearly all of our targets – not just those particularly aligned to LTC Providers are all contributing to services for LTC but they didn’t always see it.

Plymouth approach

Two streams of work needed Generic provision Bespoke provision

Generic What services are needed irrespective of the disease? Prevention and public health messages Diagnostic access A commitment to providing information and support for people about the disease A consistent approach for patient and family empowerment, and a self help philosophy

Generic ….. Medication management Intermediate care Integrated community services Single assessment process Crisis care planning Care co-ordination End of life care Information and performance indicators

Bespoke services Specialist services which understood the specific disease needs and pathway, but work in conjunction with generic services. Education and support for people around the actual disease. Work and activities of daily living support, which understood the impact of the illness. Specialist services working together in instances of co-morbidity.

Pathway redesign work Before embarking on changing any pathway need to have evidence of the following Understand our local prevalence Have listened to what our users think of our service and current provision and what they would actually want Have a picture of local service provision and advances in technology expected in the future

What will I be looking for in changed pathways? Disease prevention measures where possible. Diagnostics process including support for the person and their family. Stabilisation and optimisation (links with work, leisure etc) Education and information including self help strategies.

Continued…. Medication management Crisis management Information sharing Co- morbidity links End of life care

How did we decide on priorities? Able to demonstrate that the service improvement already occurring supported LTC management. Considered cost, numbers, appetite for change, ability to influence and opportunities. Aligned this with strategic objectives and national priorities which could help our cause e.g. 18 weeks targets. Currently using the NHS institute to help.

Evidence of improving outcomes Stroke Association management of patient information Unique model of care for community matrons in Plymouth. MS pathway work, clear understanding of need before looking at pathway, leading to change in priorities. Development of community cardiac options and expansion in cardiac rehabilitation. MND network development

In summary…. This type of approach allows commissioners to helicopter across all providers and discourage the creation of lots of ad hoc service provision. It enables commissioners to really think about shifting money across the services (and achieve it). For us it helps to makes sense of a massive agenda.