1. Long Term Conditions Overview Tuesday, 22 May 2007 Dr Bill Mutch

2. LONG TERM CONDITIONS “THE HEALTH CARE CHALLENGE OF THIS CENTURY” 4 Dedicated Editions of B.M.J 78% of all NHS Resource 80% of GP Consultations 60% of Hospital Bed Days 61% of 75-84 One Long Term Condition 22% of 75-84 Two or More Long Term Conditions

3. Monitoring Poverty and Social Exclusion in Scotland 2004Joseph Rowntree Foundation

4. DELIVERING FOR HEALTH THE CARE PARADIGM SHIFT CURRENT VIEW Geared towards acute conditions Hospital centred Doctor dependent Episodic care Disjointed care Reactive care Patient as passive recipient Self care infrequent Carers undervalued Low tech EVOLVING MODEL OF CARE Geared towards long-term conditions Embedded in communities Team based Continuous care Integrated care Preventive care Patient as partner Self care encouraged and facilitated Carers supported as partners High tech

5. RELATED WORKSTREAMS The ‘shifting the balance of care’ workstream in Delivering for Health Implementation of Changing Lives: Report of the 21 st Century Social Work Review, and particular the self assessment tool which local authorities have completed and submitted to the Executive National Strategy for the Development of the Social Service Workforce The work of the Joint Futures Unit, especially in relation to the single shared assessment and the care management training framework Guidance on Care Management The Executive’s priorities for supporting carers, as set out in the response to The Future of Unpaid Care in Scotland and guidance on Carer Information Strategies Better Outcomes for Older People and the Strategy for a Scotland with an Ageing Population, due to be published in January 2007 Developing Community Hospitals: A Strategy for Scotland Visible, Accessible and Integrated Care, the review of community nursing The Rehabilitation Framework Delivery of action in The Right Medicine: A Strategy for Pharmaceutical Care in Scotland and the new pharmacy contract Improving Frontline Services, A Framework for Supporting Frontline Staff Workforce developments such as the Skills for Health Career Framework SPARRA (Scottish Patients at Risk of Readmission and Admission), the risk prediction algorithm which ISD published in June 2006, towards which NHS Boards’ own risk prediction tool should be converging The work plan on quality improvement in Community and Primary Care Health Services which NHS Quality Improvement Scotland is developing Palliative care gold standard E-Health Strategy Audit Scotland review of adults with Long Term Conditions – Baseline Modified from Annex to LTC Toolkit

6. NATIONAL STRATEGY FOR CARE OF LONG TERM CONDITIONS WILL: Ensure Collaborative Working Be Led by CMO Identify Good Practice Ensure Spread of Good Practice Share Learning Encourage Innovation Identify Areas that Require National Approach &Develop that Support KEY PRINCIPLES ARE: Evidence Based Care Emergent Solutions Patient / Carer Experience as Driver of Change – Open Space Events Partnership

8. CHP LTC TOOLKIT Organisation of LTC Management Patient & Carer Information and Supported Self Care Service Design and Multi-Disciplinary Multi-agency Working Interdisciplinary Education & Training Information and Intelligence Quality and Delivery

9. Empowering and enabling patients with long-term conditions to take control of their own care Source: Our health, our care, our say, DH 3-5% 15-20% Public Health, Health Improvement, Health Education

10.  Better outcomes for individuals, their families, carers and communities  Improved access to services  Reduction in the use of unplanned care  Improved concordance with medication  Reduction in the number of professionals involved in the individuals care  Improved choice  Greater continuity of support / care / involvement  More control in the package of care / support provided  Improved and speedier decision making  Empowerment of individual through active participation in the process  Improved partnership working POTENTIAL BENEFITS OF CASE MANAGEMENT