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Developing a strategy for improved long-term conditions manager

1 September 2007

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StowHealth Practice, Stowmarket

Neil has been a GP principal for four-and-a-half years. After finishing university, he returned to live and work close to his childhood home in Stowmarket. Neil has a strong interest in long-term conditions – particularly diabetes – and IT, and recently led his practice through a change in the clinical system they were using

By its very definition, chronic disease is constant, unremitting and currently incurable, while exerting an immeasurable financial and quality-of-life burden on both the NHS and patients.
With estimates of approximately 60% of adults (17.5 million) in England and Wales reporting a long-term or chronic health condition, problem strategies for continuous improvement and delivery of high standards of patient care – both within the community and the home – need to be implemented (see Box 2).
The Department of Health’s (DH) NHS Improvement Plan 2004 sets out key service priorities over four years through to 2008, including objectives for supporting people living with chronic or long-term conditions (LTCs), reducing expenditure and positively increasing their quality of life.(1) These were the challenges we needed to address so that we could effect a positive change in how we manage these specific patient groups and administer our healthcare systems.

In-practice consultations
StowHealth Practice in Stowmarket is an established primary care practice with 54 staff, serving 15,500 people in the community. Our present building opened in May 2003, although the practice has actually existed on this site for 30 years. Following participation with the Improvement Foundation’s (IF) National Primary Care Collaborative (NPCC), my team and I agreed to review how we managed our patients with LTCs.

After consultations with our staff and our patient forum, we identified two key issues with our current system, which involved separate nurse-led diabetic clinics, coronary heart disease clinics and respiratory (asthma and chronic obstructive pulmonary disease – COPD) clinics:
•    Repeat visits for patients with more than one LTC – we noted that out of our 15,500 patients, 3,353 were identified with more than one LTCs.
•    The need for subsequent GP consultations to perform medication/prescription reviews – we noted that 4,629 individual LTCs required a review.
Our challenge was to improve
efficiency and streamline management systems to develop our own long-term medical conditions (LTMC) clinic. In doing so, we have successfully transformed and enhanced services for our patients
and staff.

Primary care collaboration
The management of LTCs is concerned with diseases that can only be controlled, not currently cured. The IF’s NPCC has been operational since October 2003, and focuses on developing the capacity and capability in primary care to deliver care advances for patients living with chronic diseases, via the methodology of application improvement.
Comprising nurses, GPs and specialists – but moreover the patients or carers themselves responsible for improvement within primary care trusts (PCTs) – the programme utilises existing best-practice templates, specifically those for diabetes and COPD, which can be applied to other LTCs.
Key elements of the IF programme have been:
•    Patient and carer participation.
•    Strong emphasis on self-care.
•    Development of robust integrated pathways between primary and secondary care.
•    Development of case management
at practice level.
•    Desire to reduce unplanned hospital admissions and subsequent length of inpatient stays.

How we are achieving successful patient and practice outcomes
Here at StowHealth Practice, we have realised a rewarding success in both patient satisfaction and best-practice management. In implementing a number of new or improved systems and procedures, efficiency has increased tremendously while reducing our expenditure.
•    Computer database – we have installed a separate computer database that allows doctors and practice staff to search any combination of LTCs
(such as hypertension, diabetes or asthma), as well as the patient demographic data.
•    Recall letters – we now have tailor-made patient recall letters, which reference the patient’s individual disease profile.
•    Recall system – a mechanism to identify and monitor patients unresponsive to recall.
•    Coded letters – as each letter carries a code, our reception team are able to access the exact text of the letter, and respond quickly and efficiently to patient enquiries and/or appointment bookings.
•    In-practice patient self-monitoring – we have installed an automated blood-pressure machine and weighing scales to encourage and facilitate patients to become more responsible in monitoring their disease.
•    Practice intranet – we have installed management protocols for each LTMC clinic, which are then easily accessible via the practice computers.
•    Healthcare assistant (HCA)
health checks – patients with a vascular condition are invited for assessment with an HCA. This one-to-one consultation has had the benefit of opening up better communication with patients, and has helped create an environment where they feel more at ease discussing issues they might not raise with their GP or nurse.
•    LTMC assessment – approximately two weeks following an HCA assessment, and when all test results have been reviewed, our patients attend the LTMC clinic. Run jointly by the nursing and doctor teams, each of the patients’ identified conditions are assessed, with an opportunity for all to explore and discuss any problems. The LTMC assessment also allows for the doctor to review patient medication/prescriptions.
•    Personal management plan – we are particularly proud of the personal management plan given to each patient regarding their condition, and next recall to the LTMC clinic.

Patient outcomes successes
After a three-month evaluation, we studied the acceptability of the new system and sought feedback from all practice staff and patients. With an overall 95% positive approval rating, patients are more empowered towards better self-care, and enjoy the extra time to discuss their condition during the HCA assessments.
Crucially, we have learnt to better understand and monitor the complex interactions of LTCs than when we first looked at them as separate entities.

LTMC clinic – reaching our goals
After 15 months of running our LTMC clinic, we are proud to have achieved the following outcomes:
•    Significant reduction in our “did not attend” (DNA) rate from 20% down
to 7%.
•    60% decrease in the number of acute admissions for respiratory illness in our patients with COPD.
•    105% increase in the number of patients with diabetes with a cholesterol reading < 5 mmol/l.
•    82% increase in the number of our patients with diabetes with a blood pressure of less than 145/85.
•    29% increase in the number of patients with diabetes with an HbA1c of 7.4%
or less.
Overall, we have reached all of the above goals while reducing patient visits to the practice for LTC care by 20%.

Review and analysis of our current LTCs management led to change in our practice’s approach. Following the IF’s principles and methodologies, we have successfully reached new levels of administration and care delivery.
With the input of our patients, invaluable feedback has allowed us to consolidate our findings and improve working practices that have far-reaching effects for both staff and patients, as well as our expenditure.

1. Department of Health. The NHS Improvement Plan: putting people at the heart of public services. London: HMSO; 2004. Available from:
2. Lyon D, Lancaster GA, Taylor S, Dowrick C, Chellaswamy H. Predicting the likelihood of emergency admission to hospital of older people: development and validation of the Emergency Admission Risk Likelihood Index (EARLI). Fam Pract 2007;24(2):158-67.