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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 ambition 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:

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):

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:

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.

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.

Other commissioning actions:

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:

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.

What we are doing over the next five years

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 here.