Chronic Conditions

Background

Asthma pumpChronic conditions are those which in most cases cannot be cured, only controlled, and are often life-long and limiting in terms of quality of life.
They include: 
The impact of chronic conditions on people’s lives and services in Wales is of growing concern. Wales has the highest rates of long-term limiting illness in the UK accounting for a large proportion of unnecessary emergency admissions to hospital . (Source: Designed to Improve Health and the Management of Chronic Conditions in Wales: An Integrated Model and Framework )

To view more information on chronic conditions from a patient’s perspective see the:

Policy Context

Designed to Improve Health and the Management of Chronic Conditions in Wales: An Integrated Model and Framework  is a mainstream programme of action which aims at refocusing services and resources to meet local needs more effectively through partnership-working  with all stakeholders including patients, service users and carers.

A series of 4 Directives on Chronic Conditions have been issued by the Welsh Assembly Government. These are aimed at improving the management of specific Chronic Conditions.

National Service Frameworks provide a systematic approach to tackle the agenda of improving standards and quality across a number of healthcare sectors. They include specific frameworks for Diabetes, Coronary Heart Disease, Mental Heath and Renal Disease.

Designed for Life is the Welsh Assembly Government’s 10-year vision for creating world-class health and social care in Wales in the 21st century. It highlights that improving the management of chronic conditions is a necessary and key part of achieving sustainable, effective and efficient health and social care services in Wales.

The Wales Audit Office report on the management of chronic conditions found that too many patients with chronic conditions are treated, in an unplanned way, in acute hospitals. Chronic conditions account for at least one in six emergency medical admissions

What is NHS Wales doing about Chronic Conditions Management (CCM)?

News Article

 

Service Improvement Initiatives

The National Leadership and Innovation Agency for Healthcare Chronic Condition Management (CCM) programme builds on the work achieved by the Integrated Care Pathway (ICP) Programme. Much of the ICP Programme's work focused on developing CCM pathways to reduce the risk of hospital admissions and improve the quality of patient care.

The National CCM Demonstrator Programme has been established by the Welsh Assembly Government and involves innovative project work to test the Chronic Conditions Model and Framework in Cardiff, Carmarthenshire and North Wales (Gwynedd). Each area has a particular focus on new integrated and collaborative working practices within the CCM community and the third sector, as well as specific studies in service improvement, IM&T, workforce re-design and citizen engagement.

Informing Healthcare is working with health professionals and data analysis experts to develop a computer-based information tool PRISM that will stratify GP practice populations against their risk of having an emergency admission for a chronic condition.

Health Solutions Wales have developed a web-based Welsh Predictive Risk Service tool. It manages and makes potential changes to the model through users. It will also incorporate the risk scores and make them available to GPs and health professionals in support of their daily and future planning activity. In time, some of it may also provide other risk information derived from sources other than PRISM.

The Welsh Assembly Government’s common framework of Health Care Standards for Wales supports the NHS and partner organisations in providing effective, timely and quality services across all healthcare settings.

The General Medical Services (GMS) contract is a strategic tool to improve the quality and range of services for patients including enhanced services for diabetes for example; and to give Local Health Boards the ability to shape services, increase primary care capacity to meet local needs, and to tackle wider problems across the whole NHS

The Quality and Outcomes Framework (QOF) is designed to improve the quality of services and to make it easier to monitor the quality of service patients with long-term conditions receive in primary care. 

The Cardiac Networks of Wales were established in September 2002 to take forward the implementation of the National Service Framework for Coronary Heart Disease.

Telehealth is the delivery of health related services and information via telecommunications technologies. The telehealth concept runs through a number of Informing Healthcare's service improvement projects for Chronic conditions management.

Informing Healthcare’s Clinical Pathways Project is focussed around ‘Map of Medicine’, a knowledge tool for clinical decision making. The project is currently rolling out the Map of Medicine across NHS Wales, supporting its implementation, evaluating the benefits and business need for a clinical pathways tool. 

Map of Medicine Healthguides is a web-based visual representation of evidence-based patient care journeys covering 28 medical specialties and over 340 pathways. It is an NHS England resource.

Condition Management Initiatives

The Expert Patients Programme Wales (EPP) provides a range of self-management courses and workshops for people living with long-term health conditions or for those who care for someone with a long term condition.

Local EPP courses are offered through Local Health Boards. Examples include:

Health Improvement Initiatives

Health Challenge Wales is the Welsh Assembly Government’s national health promotion initiative aimed at encouraging and helping people to share the responsibility for health and well being. A key aim is to help reduce the demand on heath care systems that currently arise from treating preventable ill-health. 

Local Health Challenge initiatives supported by NHS bodies are in place across Wales aimed at health improvement at community level. Examples include:

The Physical Activity and Nutrition Networks Wales are for all individuals, organisations and sectors with a role to play in improving nutrition and levels of physical activity in Wales. They aim to share good practice in health improvement and lifestyle advice.

Publications

A Profile of Long-term and Chronic Conditions in Wales was commissioned in 2005 to gain a clearer picture of chronic conditions in Wales and their impact. It drew from the existing data sources at that time.

Resources

National Institute for Health and Clinical Excellence (NICE) Guidance is designed to promote good health and prevent ill health, is evidence based and produced by the people affected by our work, including health and social care professionals, patients and the public. It is internationally recognised for its excellence.

NHS Evidence is an NHS England Resource

NHS Wales e-library for Health is an online resource for NHS Wales professionals.

Statistics

Statistics from Primary Care which measure achievements against the Quality and Outcomes Framework including the monitoring of Chronic Conditions.

The latest National Statistics from the Welsh Health Survey produced by the Welsh Assembly Government were released on 29 September 2009 according to the arrangements approved by the UK Statistics Authority.