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Gearing up CCGs for the LTC challenge

Most GP commissioners realise something major has to be done to change how long-term conditions are managed. What is it they really need to grasp?

The principle issue is to think carefully about how people are currently managed, to identify proactively the people at greatest risk of admission – by doing this in an integrated way with colleagues in community services and social care, we can look after more people at home, prevent admission and get better outcomes. It's ultimately about looking at how services are distributed between the hospital and community.

How you configure integrated care teams is an essential element of this (QIPP model – see box, page 23), and that requires commissioning with a number of organisations. But let's be clear – the driver is about improving quality of care for people. You know from personal experience of discussing with patients that they usually see somebody different with no reference point of what's gone on before, whereas what we create in primary and community care is a longitudinal relationship and continuity. If these drivers were simply about making savings, then I wouldn't be doing it.

Is this an area that requires GP commissioners to ‘get into' practices and change what happens there?

I think it's more that commissioners can assist practices to do what they've been trying to do anyway. The core business for practices by and large is seeing people with long-term conditions, and too often there are decisions that have fragmented the teams we've worked with.

I talk about us having detached community nursing rather than attached, and I know that colleagues throughout the country have felt the same. There's an opportunity here to get back to a team approach that we know can work really well. For the risk-profiling part, practices would have to partake in looking at the higher at-risk – not on their own, but with the integrated care teams.

The idea that all this just rests entirely on practices is not the case – this is actually practices participating with their colleagues in community and social services to have an integrated approach to managing those with long-term conditions.

People I talk to who have gone down this route most vigorously tell me they wouldn't go back, so I take it from them, as well as the research literature, that this is something we should be doing.

But for most community services, the reality is detachment. For this to work, presumably you need that connection?

This goes back to your first question of what CCGs need to do.

CCGs are thinking about how do you create these integrated care teams from the community provider – and as can be seen in Brighton and Sussex and Barking and Dagenham and Kirklees and other places,  people are being able to get though that more swiftly than they used to because the community service provider knows that they're talking to the commissioners of their services and that has created more ‘flexibility', shall I say, in the response.

The providers recognise they are dealing with their customers, and also don't forget something like 28-30% of community providers are integrated with foundation trusts, and foundation trusts are recognising it's in their interests to maximise the community element of what's being provided –  so there's a synergy there. I'm also pretty certain the NHS Commissioning Board is going to be setting priorities in terms of what's going on in community services.

Some grassroots GPs might feel they do all they can in an eight-minute consultation.

To ask them to move to a system that requires them to risk-profile their patients and connect with a integrated care team – that's a big ask, isn't it?

This misunderstands the nature of the task. The risk stratification is as automatic as understanding your QOF.

The initial set-up is three runs that are done by the person currently at the PCT – but I guess that might be clusters or CCGs – in order to set up your system to interrogate your clinical software. After that it's simply a question of doing a run every fortnight or month, and that gives you a list in the same way that if I wanted to identify from my family records the number of patients who have a family history of coronary heart disease, raised blood pressure and smoked, I could put those in and print them out.

It's a very similar mechanism to the QOF so the work in producing the lists is minimal. It's what you then do with the list and how you engineer the management that is difficult, and that's not something you do in an eight-minute consultation – it's something you do in a weekly or fortnightly meeting with your colleagues in the same way that used to happen years ago and still happens in many places now. It's just creating a focus around that discussion. Many practices now have similar meetings around end-of-life care for patients. It's an analogous meeting, but around proactive management of people with long-term conditions.

I think this is where the role of the CCG will come in as well. We're in an era where there are going to be fewer resources – and this is if you take the best case – where health inflation has traditionally outpaced the retail price index and will certainly outpace economic growth. So whether you call it QIPP or call it something else, learning how to eliminate waste and get more for the money will be as key to patients as having a knowledge of the clinical elements. So a CCG will have to start looking at variation within its patch  because at the end of the day, the shareholders or taxpayers pay our wages and when resources are tight it will lead to increased scrutiny of the variation that exists. That's a personal view, and I'd like to stress that.

Is this going to push CCGs onto new ground in looking at variation?

I wouldn't wish to presume how CCGs will deal with it. All I'm saying is that if I look at it strategically, it must be on their agenda.

What sort of things would you say CCGs need to look at?

Again, I'm not going to determine that. But as a broad issue, if resources are constrained – which, in my view, they are and will continue to be – the variation of performance is something that's going to come more to the fore than it does now.

And if people doubt that, look at the excellent Atlas of Variation. I looked at a presentation from Blue Cross where they were looking at the hypertension medication used by clinicians in their block, and there was a variation between individual clinicians who were never using the most expensive and least effective drug to those using it 100% of the time – they can't both be right.

But the cost variation was huge, and the evidence around what should be used first was robust – and yet people didn't do it. So in that situation, there was a massive variation and if you looked at most practices within a CCG you would find considerable variation. In fact, looking at individual GPs within a practice there's considerable variation. We don't talk about it much. I'm simply flagging up that in the next few years, we will be talking about it.

This is me being predictive, not saying what should happen and I must stress that. I'm simply looking forward. Were I in a CCG in a leadership position, I would be thinking about how we can frame that in terms of quality and do it in quality improvement and peer review, not performance management. You have to frame this.

I know from my 15 years of working in quality improvement in different countries around the world that the key thing you can do that starts a conversation about improving quality is be transparent about the data and the outcomes people are achieving, and you almost don't have to do anything else. You put that on the table and it creates a conversation, and that is about asking: ‘What are you doing that I'm not doing?'

Another example outside general practice is one country where they looked at the registry of outcomes for childhood leukaemia. They found two organisations were doing much better than everyone else.

These two organisations were outliers in performance in terms of the outcomes they were getting, and when they looked closer they found those organisations – albeit separately and differently because they'd not communicated with each other – were paying much more attention to the nutrition of the children, very detailed attention.

Within six months, the other organisations in that country started doing the same and because of this outcomes rapidly shifted for a whole load of kids.

You imagine that we're going to be able to demonstrate how we can improve aspects of patient care in different ways, so routine analysis of variation and how to improve care of patients seems to me the right way to go.

If I was leading a CCG right now, I'd be recognising that was going to come about and I would be setting it up so that the model was around quality improvement, not performance management.

Patients with long-term conditions are often treated in silos when under hospital care – how can that change?

This is why we're creating these three drivers, which are about moving it away from treatment in silos and creating the year-of-care tariff.

With the data that we started out with, anyone who thinks they can just work down disease-specific silos is ultimately disadvantaging the population they serve, because they can't carve patients up in that way.

If you look at what patients say in surveys and summarise it, they say: ‘I want you to treat the whole of me and act as one team.' That's where we need to get to.

Depression is a common comorbidity, yet services are still lacking in many areas. How can CCGs tackle that?

You're right. The majority of people with long-term conditions have depression, but if you drill further down one of the reasons for this depression can be that when people are whizzing in and out of hospital, they don't feel they're in control and they don't feel like people. And this is where we come on to the self-care element – patients who feel empowered to help manage their own conditions feel more enabled and as such are less prone to depression.

Finally, let's talk about telehealth. There's a very big market opening up here. Should CCGs embrace it?

My advice to CCGs would be to change the system first, put the kit in second. We're very good at adding things in this country, but not at stopping doing things. For many of the telehealth programmes around the country, the protocol for nurses and everyone else has stayed the same.

So somebody who used to go to six different outpatients appointments before telehealth might think the telehealth is wonderful, and their carers think it's wonderful, they have knowledge of their disease and they can print out the graphs – but they now go to seven different outpatients clinics.

So changing the system and protocols as well as putting in the telehealth is what you need to do. Having said that, telehealth has a enormous potential for transforming the way that we manage people with long-term conditions and we should grab it, but we should do it as substituting what we do now, not adding to it.

Sir John Oldham is national clinical lead for quality and productivity for the Department of Health.

The three primary drivers

Three key actions underpin the DH's new QIPP model for long-term conditions: risk profiling, integrating health and care teams, and systematically empowering self-care.

1 Risk profiling

Risk profiling is the simplest of the three activities. Software is used to extract data from primary, secondary and social care records to produce a list of patients with long-term conditions most at risk of admissions or A&E attendance.

Lesley Callow, one of seven national coaches giving local NHS teams monthly support to transform the management of long-term conditions, advises starting with primary and secondary care data to stratify population risk. ‘It's difficult to get systems from health and social care to talk to one another,' she says. ‘Lots of our sites are now putting the NHS number [of a patient] onto any social care documentation so they can eventually pull in data from social care. The number wasn't routinely added in the past.'

Evidence sample

• Stuck AE et al. Comprehensive geriatric assessment: a meta-analysis of controlled trials. Lancet 1992;342:1032-6

• Conn V, Valentine J and Cooper H. Interventions to increase physical activity among aging adults: a meta-analysis. Ann Behav Med 2002; 24:190-200

• Fagerberg B et al. Effect of acute stroke unit care integrated with care continuum versus conventional treatment. Stroke 2000;31:2578-84

2 Setting up an integrated team

The aim of setting up generic multidisciplinary teams is to move away from single-disease silos of care and to stop patients falling through the gaps as they are shifted from GPs to social workers, nurses, outpatients and other services.

Integrated teams do not have to work under the same roof, but they must meet regularly – in person or through teleconferencing – to review at-risk patients and jointly decide care packages.

Ms Callow says teams, at a minimum, should comprise GP, nursing and therapy input, as well as case managers and case co-ordinators: ‘If you haven't got somebody co-ordinating all those organisations and processes, things will go awry. The case co-ordinator needs to keep patients and carers informed of what's happening, what to expect and who's due to see them.'

Some teams use community matrons as co-ordinators and others use administrators, Ms Callow says. She adds that it is important to be able to call for specialist advice if conditions exacerbate for the patient.

Evidence sample

• Kasper E et al. A randomised trial of the efficacy of multidisciplinary care in heart failure outpatients at high risk of hospital readmission. J Am Coll Cardiol 2002 ;39:3

• Griffiths T et al. Cost effectiveness of an outpatient multidisciplinary pulmonary rehabilitation programme. Thorax 2001;56:779-84

• Capomolla S et al. Cost/utility ratio in chronic heart failure: comparison between heart failure management programme delivered by day-hospital and usual care. J Am Coll Cardiol 2002; 40: 1259-66

• Opie J, Doyle C and O'Connor DW. Challenging behaviours in nursing home residents with dementia: a randomised controlled trial of multidisciplinary interventions. Int J Geriatr Psychiatry 2002;17:6-13

• Stroke Unit Trialists' collaboration. Organised inpatient care for stroke. Cochrane Library 2004;2

• Ahlmen M et al. Team versus non-team outpatient care in rheumatoid arthritis. Arthritis Rheum 1988;31:471-9

• Goodwin N et al. Integrated care for patients and populations: improving outcomes by working together. King's Fund and Nuffield Trust, 2012

3 Empowerment of patients to self-care

Improving patients' self-care requires a big culture shift in the NHS. While patients with long-term conditions usually receive literature and talks with specialists and nurses, the system needs to change ‘so that the professional is seen as a partner in care and not the expert', says Ms Callow.

In particular, clinicians will be taught to incorporate three key processes into routine practice: agenda setting, goal setting and goal follow-up with patients.

‘The role of the care professional is to support people by promoting self-confidence and self-care, helping them feel more in control of their lives, supporting problem solving and directing them towards the type of support and information they need for any aspect of their life, not just their health condition,' says Ms Callow. ‘This means listening to their goals and having a more outcome-focused approach to planning and reviewing their individualised care plan.'

Evidence sample

• Woolacott N et al. Systematic review of the clinical effectiveness of self-care support networks in health and social care. York: Centre for Reviews and Dissemination (CRD). CRD Report 342006.

The King's Fund/Nuffield Trust study (see Goodwin et al above) and others emphasise the need to implement all three primary drivers.

A core piece of research on long-term conditions is Ed Wagner's Chronic disease management: what will it take to improve care for chronic illness? (Effective Clinical Practice 1998; 1:2-4) which acknowledges that a substantial portion of chronic care takes place outside formal healthcare settings and focuses on linking informed, active people with proactive teams of professionals.

• For more information about the QIPP drivers and to download podcasts and example data-sharing agreements, go to commissioning-for-long-term-conditions