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Introducing a new approach to support people living with long-term conditions in north central London

From October 2023 GP surgeries across north central London (NCL) will be supporting people living with certain long-term conditions in a different way, adopting a new model of care which focuses on personalised care and treatment to help them manage their conditions effectively and prevent health issues escalating wherever possible.

Around 430,000 people in NCL are living with one or more long-term condition (LTC), with metabolic and respiratory illnesses, such as diabetes and asthma, making up 72% of these conditions.

Evidence shows that people are more likely to develop LTCs at an early stage in their lives if they are experiencing inequalities, which could be linked to several factors such as limited access to healthcare, education and employment opportunities or poor housing conditions. People living in areas of high deprivation, for example, can develop LTCs 10 years earlier than those living in more affluent areas, resulting in more years lived in poor health or a shorter life expectancy.

Lifestyle behaviours such as poor diet, lack of exercise, smoking and drinking alcohol also play a role in increasing the chances of long-term health problems too.

With more and more people living with or at risk of developing a LTC in NCL, we’re taking a proactive approach to improving outcomes, by addressing some of the inequalities faced by different groups in our population and identifying individuals at an earlier stage, especially in those boroughs where there has historically been less focus and resource available.

We hope that by planning care together with patients, we will help them build the confidence to manage their health successfully, reduce their risk of being admitted to hospital, and generally have a better quality of life – all of which contribute significantly to NCL Integrated Care System’s (ICS) ambition to improve population health across NCL.

As well as treating people with LTCs, this new approach focuses on proactively identifying people at risk of developing LTCs, with earlier detection and diagnosis so we can help people manage their conditions at a early stage.

How have we developed our approach?

The model has been developed around the Year of Care methodology, an evidence-based approach which puts personalised care at the heart of delivery. Residents living with long-term conditions and the voluntary, community and social enterprise (VCSE) sector have also co-designed aspects of the provision.

It will make use of the wider primary care workforce, as well as involve closer collaborative working between primary care and other system partners in NCL including hospital trusts, Councils and the VCSE sector to deliver joined-up care that will holistically address the individual’s health and wellbeing.

Elements of this new approach have already been trialled in practices across Camden and Islington since 2016, with impressive results.

For example, in Camden during 2022/23, 1,027 new cases of people living with hypertension and 500 new cases of people living with diabetes were identified through the trial collectively by practices. This means more people will receive better tailored, ongoing care to empower them to manage their conditions effectively.

In Islington, patients benefitted from receiving personalised care that helped them make better decisions about their health and wellbeing. For example:

Islington case study: A long-standing COPD patient was very fed up with his annual reviews and being asked to stop smoking. Through a care planning conversation, we identified that what was most important to him was taking his grandkids to the park. However, his unbearable back pain got most in the way of his enjoyment in life, so smoking was one of his only pleasures and helped to control his pain. With this in mind, we reviewed his back pain, supported him with his mood and with a holistic approach, he was willing to attend pulmonary rehabilitation and reduce his smoking intake by half. He now engages more fully with his annual reviews.

Working as a system

Building on the success of these pilot schemes, we are leading the way amongst other ICS’ in England by rolling out a consistent locally commissioned service for long-term conditions, achieving 100% sign-up from every NCL GP practice to deliver the new model of care.

Taking a consistent approach in the way people are supported to manage their conditions will ensure more equitable access to the care they need, which will in turn help to reduce health inequalities and lead to better health outcomes.

Empowering more people with the right tools to stay well also means that resources can be utilised more efficiently across the ICS resulting in positive outcomes more widely for the communities we serve.

The service will operate using a unique funding model that provides payment to GP practices based on patient outcomes, as well as service delivery.

Additional funding is being provided for practices to particularly focus on improving the health outcomes of people from ethnic minority backgrounds in NCL, who live in the greatest areas of deprivation and experience some of the highest inequalities. The extra investment could enable practices to strengthen relationships with local VCSE groups who can reach these communities, and encourage good health habits and engagement with services.

Dr Katie Coleman, Islington GP and Clinical Lead for the programme said: “It has taken years of thorough planning to get to this stage, achieving sign-up from every single GP practice in north central London who has committed to delivering this new model of care.

“We are extremely grateful to colleagues and patients for their valuable contribution to developing a comprehensive service that can be tailored to the varying needs of people living with long-term conditions.

“By working closely with people to identify and address areas that matter most to their health and wellbeing, this new approach will empower them with the skills and confidence to manage their conditions and help them have a better quality of life.”

The conditions covered under this new service are:

  • Diabetes
  • Cardiovascular disease for example:
  • strokes, transient ischaemic attack (mini stroke)
  • heart failure (inability of the heart to pump blood round the body properly)
  • ischaemic heart disease (narrowing of coronary arteries due to fatty build up), and
  • peripheral artery disease (slow, progressive circulation disorder)
  • Hypertension (high blood pressure)
  • Hyperlipidaemia (high cholesterol)
  • Non-alcoholic fatty liver disease
  • Atrial fibrillation (condition causing an irregular and often abnormally fast heart rate)
  • Chronic kidney disease
  • Asthma
  • Chronic Obstructive Pulmonary Disease (COPD)

The new model of care – how it will work

People who have been identified as being at risk of developing or have already been diagnosed with conditions covered by the LTC LCS will be invited by their GP surgery to have a Yearly Health Check. This will consist of three appointments (Check and Test Appointment, Discussion Appointment and Follow-Up Appointment).

Across the course of the year, depending on what their situation is, individuals could have the opportunity to work with different health professionals including GPs, nurses, health and wellbeing coaches, and social prescribers.

Appointment discussions will focus on:

  • identifying what is important to their health and wellbeing
  • setting personal goals and what would need to happen to achieve these and
  • deciding on actions which will help them to successfully manage their condition(s).

People may be offered advice and support to help them eat well, exercise, stop smoking, to get better sleep, as well as seasonal health advice such as how to stay well in winter.

They will also have the opportunity to discuss other areas of their lives that may be impacting on their physical and mental health and wellbeing, such as housing or employment and be linked into the appropriate agencies / services for any additional support required.

This new way of working will mean that people are directly involved in, and making decisions about, their own health and wellbeing.

To ensure the service continues to meet patients’ needs and help them achieve better outcomes, a range of measures will be put in place to evaluate its effectiveness and drive future innovation. Patients who have been through the Yearly Health Check will have the opportunity to feedback on the process which will help practices understand what works well and address areas for improvement.  Patient Participation Groups (PPGs) and wider community engagement, through the local VCSE, will also play a key part in service development.

Eligible patients will be contacted over the year by their GP surgery.