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[Digital Health Guide] Better care for long term conditions

Written by Steve Marriott on 16-Jan-2018 07:33:53

long term conditions.jpgOver 22% of the UK population has at least one long-term condition. That's more than 15 million people with conditions that have no cure. Managing these patients' chronic diseases for the rest of their lives will be expensive. There's a human cost too. How does living with one or more long-term condition impact a patient's quality of life?

A perfect storm

Interrelated factors are creating pressure on the NHS:

  1. The population is increasing. ONS data shows an increase of 4.7 million people over ten years. Their predictions suggest the UK population will increase by a further 4.2 million people by 2027
  2. We are living for longer. Improvements in healthcare and lifestyle are leading to an older population. In 2016, 2.4% of people in the UK were 85 or more years old
  3. Long-term conditions are more prevalent in older people
  4. The number of patients with multimorbidity is increasing
  5. The number of GPs is declining. In November 2017, The Independent reported: "The NHS has lost the equivalent of 1,000 full-time GPs in the past year."

The digital healthcare revolution

We are on the cusp of a digital healthcare revolution. Today, it's easy to share patient records, work anywhere and analyse health at scale. Interoperable systems, mobile technology and population-level healthcare enable healthcare services that:

  • encourage collaboration across NHS sectors
  • identify patients who are not receiving appropriate care
  • standardise care
  • are sustainable
  • improve the patient experience

Here is our guide to help you get started.

Identify undiagnosed patients

The quality of patient data at GP practices is variable. It's easy to overlook adding diagnostic codes at the end of a consultation. With no diagnosis on their record, a patient will not receive appropriate treatment. Risks include avoidable decline, further complications and premature death.

You can identify these patients by analysing their medical records against various scenarios. For example, the parameters for diabetes would include HbA1c results, other specific blood tests and the Leicester Diabetes Risk Score. For COPD, the patient's age and smoking status are of interest. So are any recent prescriptions for an inhaler or antibiotics for a chest infection.

You could do this case finding at a single GP practice. But it makes more sense to build the lists of patients at scale, for a cluster, federation, CCG or health board area. We call this population-level healthcare. Clinical reviews can then confirm diagnoses so appropriate treatment can begin.

In 2014, Greenwich had the highest rate of years of life lost due to avoidable death in South East London. Compared to the national average, the prevalence of four long-term conditions in the area was low. There was a significant number of residents that might be undiagnosed and untreated. The CCG used Outcomes Manager to find these patients. In the first year alone, they were able to identify and diagnose over 4,000 patients.

There's an in-depth look at population-level healthcare and case-finding in Greenwich on our website.

Download a PDF of the Greenwich CCG Case Study

Target lifestyle advice

Similarly, you can step in earlier and identify those people at risk of developing long-term conditions. Targeting these people with lifestyle advice may encourage them to live healthier lives, an essential step towards preventing avoidable diseases.

Standardise care

Population-level healthcare helps commissioners understand how they can improve services for better care. But, it is a challenge to make clinicians aware of these changes. This is particularly true in areas where there is a shortage of GPs and a reliance on locums.

Outcomes Manager closes the loop. You can build pathways and data entry forms for clinicians to use in consultations. You can deploy these to every clinician in every practice. And it doesn't matter which clinical system they use. This ability to influence a change of behaviour improves compliance with local policies.


Collaborative working can improve the provision of care for patients with long-term conditions:

  1. GP practices working together can share resources for screening services and disease-specific reviews
  2. Multi-specialty teams across sectors of the NHS, such as end of life care, can care with compassion
  3. Care in the community allows care to take place at the patient's home. This is especially important for the elderly and patients with frailty
Successful collaboration depends upon information and communication.

The clinician needs to understand their patient's medical situation. That's easy when a GP sees one of their registered patients. But what about clinicians and carers working at shared services or in the community? Sharing is the answer. When the clinicians working at these services can see medical histories, they can make appropriate care decisions straight away with confidence.

Interoperability allows different systems to share patient records. And there's no need for everyone to use the same IT system these days. Sharing agreements are the best way to control which parts of patient records are available for sharing, and who can access them.

Your multi-specialty team might include GPs, consultants, nurses, community teams and pharmacists. How do you communicate and discuss a patient's care needs? Vision's new tasks app allows all these people to set tasks for each other and track progress too. Online conversations make it easy to ask questions or clarify specific details.

Work smarter

Patients with chronic conditions will have frequent contact with their GP practice. There are ways that technology can help you work smarter, saving you time and improving the patient's experience:

  1. Invite patients for reviews and blood tests with text messages. It's fast, efficient and much cheaper than sending letters
  2. We are working on ways to synchronise repeat medication. Your patients won't need to contact you as often - it's easier for them and saves you time
  3. Encourage your patients to use online services. Each time they book an appointment or request a prescription online it is one less for your admin team to deal with in person

Next steps

There are many opportunities for commissioners and service providers to embrace the digital healthcare revolution. Download our eBook: an introduction to population-level healthcare.

eBook - Population Level Healthcare

Topics: Interoperability, Saving time, shared care, Online services for patients, outcomes manager, healthcare management


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