Out-of-hospital programme - transforming services for people with long-term conditions


Long-term conditions or chronic diseases are conditions for which there is currently no cure, and which are managed with medication and other treatment, for example: diabetes, chronic obstructive pulmonary disease, arthritis and hypertension. About 15 million people in England have one or more long-term conditions and a key ambitions of the NHS Five Year Forward View is to support patients with long-term conditions to manage their own health effectively, while reducing demand on NHS services.

There are differences in the way people with long-term conditions access services and with people from the most deprived areas of Bradford being less likely to access the services they need than from more affluent areas, resulting in the gap in health inequalities rising for different communities across Bradford. For example, people in more deprived areas have a shorter life expectancy than those who live in less deprived areas. We also know that unhealthy behaviours such as smoking, physical inactivity, poor diet, alcohol and stress increase the risk of long-term illness and poor health. Inequalities also exist between groups according to other factors, such as gender, ethnic background, certain sorts of disability and sexual orientation. Tackling health inequalities is a long-term process, but with the strength of partnership working we can shape joint plans for the coming years around the need to promote self-care and prevention work to help people improve their health and wellbeing. The health inequalities action plan 2013-2017 describes our commitment to reducing health inequalities in Bradford.

There are large inequalities in the rate of unplanned hospitalisation for chronic ambulatory care sensitive conditions, these conditions are known to be better supported by services in the community and should not need to go to hospital. In England the most deprived 10% of the population who have one or more long-term conditions have about three times as many emergency admissions compared to the least deprived 10% of people.  We are interested in focusing on variations in the quality of management of long-term conditions in primary, community and outpatient care which may result in avoidable demand on acute hospital services. In England ambulatory care sensitive conditions account for 15.9% of all emergency hospital admissions and there is significant variation in how effectively these are managed between local authority areas, with costs estimated in 2009/10 at £1.42 billion for a core set of 19 ambulatory care sensitive conditions (ACSC):

Note: 19 Chronic ambulatory care sensitive conditions are as follows:

  • vaccine-preventable: influenza and pneumonia; 2. other vaccine-preventable conditions;
  • chronic: asthma; 4. congestive heart failure; 5. diabetes complications; 6. chronic obstructive pulmonary disease (COPD); 7. angina; 8. iron-deficiency anaemia; 9. hypertension; 10. nutritional deficiencies
  • acute: dehydration and gastroenteritis; 12. pyelonephritis; 13. perforated/bleeding ulcer; 14. cellulitis; 15. pelvic inflammatory disease; 16. ear, nose and throat infections; 17. dental conditions; 18. convulsions and epilepsy and 19. gangrene

Our thoughts on the inverse care law

The inverse care law: those who need care the most use it the least, while at the same time those who need care the least, use it most and make better use of care services.

The inverse care law was suggested thirty years ago by Julian Tudor Hart in a paper for The Lancet in 1971, which described that those who most need medical care are least likely to receive it, whilst those with least need for health care tend to use health services more (and more effectively).  Our results show that there are differences in unplanned hospital admissions between the most deprived and the least deprived and research evidence tells us that variation in the quality of management of long-term conditions in primary care, community and outpatient care can result in increases in avoidable demand on acute hospital services.  We want to encourage those in our communities who need health care the most to make more and better use of the services available.

How are we doing (our out-of-hospital programme focus):

  • carers reported the level of their health status as 0.72, with the England average being 0.80 (highest = 0.855 and lowest = 0.719)
  • just 53.0% that is to say 1 in every 2 people with a long-term condition(s) feel supported to manage their condition.
  • primary medical care management of long-term conditions rate is 1,570 per 100,000 and this reduced slightly by Qtr4 of 2015/16 to 1,516 per 100,000. This rate is a measure of emergency admissions for ambulatory care sensitive conditions and with the rate for England at 795, we are almost double the rate of admissions than the national average.
  • there is a marked difference in unplanned admissions among the least and most deprived populations in Bradford for people with chronic ambulatory care sensitive conditions. Our rate of 1,903 per 100,000 for the most deprived in Bradford and the England rate of 929 for the most deprived, we are experiencing double the rate of unplanned hospital admissions than seen across England.


What we achieved in 2016/17

The intermediate care hub and the Bradford virtual ward: an independent evaluation which analysed the effectiveness of the Intermediate Care Hub and Virtual Ward services, in 2016, showed reductions in avoidable hospital admissions and in A&E attendances.  The service supports an average of:

  • 121 patients on the step down pathway per month
  • 56 patients on the step up pathway per month. If the service was not in place these patients would have attended A&E and/or been admitted
  • in the time the service has been running, non-elective referrals from GPs for the over 65s have reduced (comparing 2014/15 to 2015/16 SUS data). There has been a 7.23% reduction in the 65-77 years age range and a 16.82% in the 78+ years age range.
  • 83% of patients were satisfied with the service

Expanded home from hospital service: the home from hospital service is now fully incorporated into the range of intermediate care services in Bradford.  The service provides support to patients in their own homes following an admission, making sure they have everything they need to stay well and independent, regain confidence and re-adjust to living at home, and avoid a return to hospital.

  • in 2016 the service supported an average of 41 people per month. This will increase by a minimum of 20 people in 2017.
  • service user feedback is high:
    • 95% of respondents felt the service made them feel less anxious
    • 94% felt the service gave them lots of useful information
    • 100% of users would recommend the service

Multi-agency, integrated discharge team (MAIDT): the multi-agency, integrated discharge team (MAIDT) will create a person centred focus in discharge planning, using needs based assessments to determine the level of support required to help a patient return to their own home following an admission to hospital.

Community nursing services: the LTC screening service was introduced in August 2016. This service supports people who are housebound and who have LTCs, e.g. diabetes, heart failure, stroke, etc., to manage their conditions better by completing a range of screening checks in the comfort of their own home. These checks include blood tests, weight monitoring and blood pressure measurements. The team then provide feedback to the GP practice to enable them to update the person’s care/treatment plan as required.   In the first three months of operation the service received 828 referrals from GP practices.

  • 74% of these referrals were for blood tests,
  • 16% were for blood pressure monitoring and blood tests,
  • 7% were for blood pressure monitoring and
  • 3% were for weight measurements only.

Other commissioning actions:

  • GPs can now ring a single number to arrange care, in a community intermediate care bed or in a person’s own home, from an integrated team of nurses, social workers and therapists,
  • the expanded home from hospital service is now fully incorporated within the range of intermediate care services across Bradford. The service supports patients in their own home following an admission, making sure they have everything they need to stay well and independent and avoid any unnecessary return to hospital,
  • community complex care team was introduced as the first phase of a larger scale project to develop multiagency community integrated teams,
  • we have a local falls team who provide an integrated, comprehensive falls service across Bradford who provide falls exercise programme and home based strength and balance exercise programme,
  • ten percent of the community workforce will be trained to better support people and enabling individuals to implement self-care skills in the management of their LTCs. We will also see an introduction of carer navigator roles by the City of Bradford Metropolitan District Council (CBMDC) which will help carers to navigate the health and care system to access support thereby enabling them to continue in a caring role,
  • the primary care dashboard shows practice rate per 1,000 admissions for ACSC conditions – this is updated monthly and there are specific pieces of work that would support the reduction of these admissions – for example using uptake of flu immunisations during the flu season,
  • a CQUIN to address frequent attenders has resulted in multidisciplinary meetings to address the top 20 attendances and is showing a reduction in attendance for those with care plans.
  • task and finish groups have been established under the Joint GP Quality Group which is focusing on; reducing unexplained variation across practices, which will include LTC pathways; and, improving the quality of and reducing variation of prescribing for LTC management.

Our plans for long-term conditions over the next two years (2017/18 and 2018/19)

Intermediate care

Intermediate and community care providers in Bradford in collaboration with commissioners are planning a phased approach to increase capacity to meet rising demand from an ageing population with increased levels of complex health and care needs. This plan will address the challenge of implementing effective transitions between acute and community settings, the complex health and care needs plan will ultimately see developed an integrated single, multi-agency service that will support people in Bradford to receive right care, right place, first time.  The following steps will take us on a journey:

  • we will extend to a 100% the home from hospital service which will increase capacity from 24 to 50 clients monthly. The home from hospital service is made up of staff from community health and social services and aims to assist people to remain independent within their own homes for as long as possible.
  • we will commission community nursing services to enhance the single, multi-agency pathway thereby achieve effective transitions for Bradford people, by providing proactive discharge planning for elective procedures.
  • by April 2017, through better use of existing resources within the Better Care Fund allocation, City of Bradford Metropolitan District Council will further enhance this pathway and create additional capacity in Bradford Enablement Support Team (BEST). The introduction of care navigators will support people and their carers throughout transfers of care.

Improving services in our GP practices

We now have our Primary Medical Care Commissioning Strategy 2016/21 in place. With six key priorities: improve access to primary medical services; high quality primary medical care; develop the primary medical care workforce; promote self-care and prevention; collaborative working and estates, finance and contracting. Delivery of the strategy will be overseen by the out of hospital programme board with the majority of the work being undertaken by the enhanced primary care implementation group (a sub group of the out of hospital programme board). Other initiatives set out in the strategy will be delivered by other programmes, e.g. planned care.

CCGs are commissioning Bradford Care Alliance to provide extended access to GP surgeries across Bradford.

  • the roll out commences from 1st June 2017 and will cover 25% of the Bradford population – this includes patients from both Bradford City and Bradford Districts CCG and in the first instance will be delivered from one hub,
  • provision will increase to 100% of the total Bradford population by October 2018 (30 min per 1000 pop). It is not clear yet how many hubs this service will be provided from.
  • this will be extended to 45min per 1000 population by April 2019 as per the national ask.

What we are doing over the next five years

  • care is person centred and promotes independence,
  • care preferably provided preferably, in or as close to home as possible,
  • collaborative care that is integrated and coordinated,
  • care is managed using integrated care plans, underpinned by a integrated digital care record,
  • incentivising integration of care between multiple providers,
  • care provided by a skilled workforce which minimises duplication,
  • joint accountability across organisations,
  • improving outcomes across the whole care cycle rather than discrete elements of a care pathway. 

The programme is concerned with transforming services in community and there are other transformation programmes that link to the metrics related to long term conditions such as the Urgent & Emergency Care Board, Bradford Beating Diabetes and Bradford Breathing Better. You can find out about these other programmes using the links on the side menu.