Long Term Conditions

Delivering person-centred care is a core theme which cuts across all programmes of work of NHS England.  The Long term conditions programme focuses on making that a reality for Thames Valley.

Long Term Conditions Management

The NHS Five Year Forward View, sets out how the NHS needs to change, LTC approacharguing for a new relationship with patients and communities. It makes a specific commitment to do more to support people with long term conditions to manage their own health:


The CQC “Better care in my hands” report published in May 2016 makes clear that “being involved in your care is an essential characteristic of person-centred care and critical to the move to successful integrated health and care services” as set in the 5YFV.  They go further to state that the CQC can take enforcement action against care providers that do not meet the standard of ‘person-centred care’, one of the fundamental standards of care (Regulation 9)

Their recommendations for commissioners are to ensure that new models of care are developed taking account of the enablers of good involvement of patients, families and carers.  This should include;

  • Accessible information about health and care options and treatment or support for people and their families/carers
  • Flexible advocacy provision
  • Community and peer support for people to manage their care through programmes with voluntary sector partners.

Over 90% of patients would like to be more involved in their care. 85% of GPs report that they do this but only 50% of patients agree, with less than half involved in discussing or setting their own goals.

Data Source: GP Patient Survey (The latest data are from the July 2015 publication, collected during July-September 2014 and January-March 2015)

Compelling evidence for care planning

The Cochrane Review 2015, Evaluating the Effects of Care and Support Planning, a systematic review of 19 trails identified personalised care planning resulted in:-LTC best practice THamlets

  • Better physical health (blood glucose, blood pressure)
  • Better emotional health (depression)
  • No difference in subjective health status (multiple measures)
  • Better capabilities for self-management (self-efficacy)

The review found that care planning works best when it is:-

  • Comprehensive: more stages of care planning cycle completed
  • Higher intensity: more contacts over a longer period


Care Planning & Patient Education

TVSCN, in collaboration with Health Education England Thames Valley, is helping deliverHOC LTC model person-centred care using the House of Care model and training in Care and Support Planning (C&SP).

As implementation, take-up and evaluation continues across the region, the drive is to move from training to adoption as shown in the right hand wall of the House of Care (attached). Resources for the left hand wall of patient education can be found here 

Evaluation on impact

All Thames Valley CCGs have engaged with the SCN LTC programme and have included person centred care/care planning features in their LTC models of care, with GP practices, admin and clinical staff taking part in the training.

Training across Thames Valley has already delivered:

  • 2 hour care planning taster sessions delivered to 204 HCP
  • 1+1/2 day care planning training courses to 355 HCPs from 130 GP practices and integrated teams
  • Trainer capacity now extended to 8 with a further 3 going through the accreditation programme (as at Sept 2016)

CQC states that national data shows little change in patients and people’s perceptions of how well they are involved in their own care, with this being most marked for people with LTCs.

LTC offer trainingThe data gained from the Care and Support Planning programme for the Thames Valley on ‘Confidence on managing own health’ and ‘Helped put written care plan together’ are below for the time period reported in the 2015 -16 SCN Commissioning Guidance and the most recent data set for Jan – March 2016 (attached)

It should be noted the response rates for this survey are low, therefore the confidence intervals are large. While these changes are not statistically significant it is the best information available.  The SCN recommend CCGs put in place local measures to evidence the impact of care and support planning on patients and health care professionals.  Indicators and tools to build this data may include:

LTC offer training

Patient Activation & Self-management

Delivering the Five Year Forward View builds on the commitment of patient centred care, challenging commissioners to ‘achieve a step change in patient activation and self-management’. Patient Activation is a measure of patients’ knowledge, skills and confidence to manage their own health and is measured at four levels;



A systematic review and collated evidence has concluded that patients at a higher level of activation used lower levels of emergency services with fewer hospitalisations.  The Patient Activation Measure (PAM) has been used most extensively in the US and has been taken up by CCGs in Tower Hamlets and Sheffield, among others, where Care and Support Planning is embedded. Since April 2016 this has been extended to other CCGs and New Models of Care to gain traction and “at-scale” effectiveness/evidence. Within the Thames Valley Buckinghamshire CCG have successfully secured a PAM licence to complement their comprehensive LTC programme and TVSCN will work to share experiences through our network activities.

The 6 principles of patient engagement and involvement are set out by National Voices;
Pt voices - LTC PAM

Commissioner recommendation

  • Promote the uptake of care planning training, identifying from this pool clinical champions to become local trainers
  • Once identified, clinical champions to take TVSCN-supported “Train the Trainer” programme
  • Base LTC plans on the House of Care framework, ensuring effort is focussed on all aspects, with metrics and outcomes that reflect all components
  • Progress through commissioning plans the adoption of care planning in a systematic way using the rolling programme on offer through the SCN
  • Develop commissioning plans for the long term sustainability of care planning by determine number, mix of local trainers, and/or facilitators to work at team/practice level
  • Provide a rolling programme of training, on-going support,  considering audit and evaluation as recommended in guidance and to consider the wider spread across all LTCs
  • In line with Diabetes recommendation from Sustainability & Transformation Plans on structured patient education, use the recommendations of the TVSCN Diabetes patient education report to develop commissioning plans for the provision of comprehensive education for patients
  • Set up processes to capture patient needs identified in care planning consultations, and reflect these interventions in commissioning plans as defined as social prescribing
  • Take a networked approach to developing an education strategy for Health Care Professionals to support on-going education in care planning and recognising the complexity of patients with co-morbidities.

Community Neurology

Long-term neurological conditions are very common and a typical CCG may be responsible for commissioning services for 59,000 patients. Neurology has the highest spend and poorest outcome of all long-term conditions in over half of all CCGs. Services for those with long-term neurological conditions have traditionally been organised around secondary and tertiary sectors, yet care organised this way leads to delayed access to expert advice, particularly at time of crisis. 70% of NHS spending is for long-term conditions, including over £750 million on urgent and emergency admissions to hospital, but much of this is avoidable.

To meet the challenging health care needs of the population the Five Year Forward View called for the development of more integrated approaches, to improve the quality and efficiency of services and improve patient outcomes by moving care closer to home from acute settings to community services wherever possible and through better co-ordinated care, delivered where and when it is required.

NHS England has developed a Vanguard programme to pilot new models of care. One such example is the Neurology Network at the Walton Centre in Liverpool. Its aim is to reduce variation in care and provide more services to patients nearer to home by increasing collaboration between hospitals, GPs and community services in the region, ensuring patients get the right care wherever they are and when they need it.

neuro-right-careOpportunities in the Thames Valley & local STP footprints

Thames Valley SCN undertook an analysis using the focus packs issued by NHS RightCare in January and April 2016 has found that each local STP footprint and the majority of CCGs in the region (based against their statistical neighbours) have opportunities for potential savings on elective, non-elective or prescription spend for neurology care, totalling over £3 million per year in this region. 


Locally developed Transformation Guide

To achieve the national requirements set out in the 5YFV, and address local issues identified by RightCare, commissioners are encouraged to read its recent Transformation Guide for community neurology (developed in collaboration nationally and taking a wide stakeholder view), which recommends the adoption of community-based person-centred new care model for those with neurological conditions.

Features of the care model

Embracing the well developed House of Care model and a stratified approach to care from self-care through needs-led interventions to complex care, the challenge and a potential solution has been well defined for commissioners.


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