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A seamless service for long-term care
Posted on 05/12/07
P. Klein
An expert group has established a series of priorities for improving care for those with long term conditions such as asthma, Chronic Obstructive Pulmonary Disease (COPD), diabetes and Parkinsons disease.
Long term conditions affect one in five people 180,000 people in Loughborough, Charnwood, Leicester, Leicestershire and Rutland and this is expected to increase as the population ages: more than half of those aged over 60 have one or more long-term condition. Effective management can not only have a huge impact on quality of life, but free up significant resources.
Co-clinical chairman and county GP Dr Chris Trzcinski is also chairman of the Leicester Professional Executive Committee (PEC). He said: The aim is to create person-centred assessment and care planning through proven methods such as patient registries, automatic recall, review and reassessment programmes, case management services for those with complex needs and information sharing across health and social care for a seamless service.
We want to ensure patients see the right people at the right time and in the right place, this may mean extending roles of other healthcare staff involved in the care of people with long-term conditions. Many patients become experts in their own condition we need to encourage all patients to develop ownership of their condition to promote self-care.
Initially efforts will concentrate on the following conditions: asthma, chronic kidney disease, COPD, chronic heart disease, heart failure, diabetes, neurological conditions such as Parkinsons disease and MS and rheumatological conditions such as arthritis. Expert subgroups have been set up in each area to develop a clinical navigator.
While technology is unable to cure long-term conditions, it has a significant part to play in improving quality of life by assisting communication. Effective IT systems allows the information to flow with the patient, eliminating unnecessary duplication which can slow down the journey and alienate patients who have to start from scratch with each stage.
Senior clinicians are committed to encouraging innovation in reducing delays and improving access to expert advice: already a scheme offering GPs phone-based support to secondary care has been piloted in Leicestershire.
Long term conditions is one of eight key themes of the Our NHS Our Future national review aimed at improving quality, improving access and improving health and wellbeing for all. Under the review local NHS organisations have established an expert group who have identified key local priorities:
- Create a clinical navigator for long-term conditions
- Easier access to advice and support for health professionals
- Speed of communication and avoiding duplication of patient letters and patient information
- Standardise initial education and care plan
- Training and clinical supervision for extended roles
Their work will compare local services and look for best practice both nationally and internationally and feed into the development of a national vision to transform NHS services over the next 10 years.
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