1. “What matters most”: Person centred co-ordinated care for LTCs
Jacquie White ARMA Clinical Networks Project

2. NHS England LTC Strategy Goal: Improve quality of life and experience of end of life care for people with Long Term Conditions and their carers
Person centred coordinated care
“My care is planned with people who work together to understand me and my carer(s), put me in control, co-ordinate and deliver services to achieve my best outcomes”

3. Long term conditions: some facts
People with frailty
10m
People have two or more LTCs
0.35m
At end of life
16m
People have one LTC
50% pop with LTCs
16m with 1LTC ,10m with 2 or more, 1m with frailty, 0.35m at end of life
15% kids aged have LTC
70% health budget on LTC
33% GP consultations on people with multimorbidty
3.2% of people with LTCs have a care plan
0.01% year of a person life on average access NHS rest self care (or 4 hours per year)
7m emergency bed days are for over 85
50% of total emerg bed days for over 75s
3 fold increase in cost of health care if got frailty
4% of over 65s in care home which equates to 14% total emerg admiss for over 65
25% hosp beds occupied by someone dying

4. Why an MSK clinical networks project – and why are NHSE supporting it?
Musculoskeletal conditions alone account for more than 100 million GP appointments each year, and many are repeat appointments.
The single biggest cause of the growing burden of disability in the UK. Much of this is avoidable disability
Together with mental health account for over half the overall burden of disability in the UK
Have an enormous impact on the quality of life of millions of people
Are associated with a large number of co-morbidities, including diabetes, depression and obesity.
Account for over £5 billion of NHS spending per year.

5. How does that translate into objectives for MSK?
Reduce inequalities and improve outcomes for patients with a MSK condition
Develop ways to measure and evidence successful MSK services
Define the skills needed to provide MSK patients with the best outcomes
Support a culture that shares knowledge, best practice and lessons learnt.
Embedding personalised care and support planning as the core component for PCC.

6. Who does the ARMA Clinical Networks project fit into the wider MSK programme?
Aim: Bringing knowledge together and bringing people together. 3 main elements: National expertise and guidance from the 4 National Working Groups Key resources The Knowledge Network

7. Involvement in system innovation
Important role of trusts in freeing up your time to support system change
Understanding the value of transformation programmes
Help us help you – send us your details of any newsletters, blogs or social media that we can highlight the importance of these initiatives to trusts and wider employers. Or help us write something new!

8. LTC Strategy for Person Centred Care:
Care & Support Planning
Embedding personalised care and support planning as the core component
Evidence
Improving evidence and implementation of it to commission better care
Engagement
Raising professional and public awareness of and engagement with PCC
Models of care
Increasing co-ordination and continuity of care though development and testing of new models
Enablers
Strengthening the enablers that drive change including data and incentives
Inequalities
Focussing on areas of inequality – care homes, Neuro, MSK, palliative care for non-cancer conditions

9. For example… using behavioral change to open minds!
Call to Action:
For clinicians to write to the person directly and CC their GP rather than the other way around
Tools and Resources:
Slidedeck from Rob Elias, Kings College Hospital uploaded to slideshare
Engage a few activated people on twitter
Outcomes
Activating patients and staff to
Support people to develop the knowledge, skills and confidence to manage their own health,
Enhance their own sense of well being
Develop skills to empower independent living.
#A4PCC
#A4PCC – Action for Person-Centred Care

10. Questions… Thank you @jaqwhite1 #A4PCC Our declaration:
Questions…