What is the challenge your project is going to address and how does it connect to the theme of 'How can we improve across system boundaries?​

1 in 3 adults in the UK are living with a long-term conditions (LTCs), also defined as a non-communicable chronic disease. The current approach to managing service users, who have multiple LTCs, is usually based on traditional episodes of care where each condition is managed in isolation and reviewed separately, resulting in patients having avoidable additional appointments.

This disempowers the patient. Those at highest risk have multiple LTCs but are not supported to make decisions across LTCs that are based on their needs. This is an inefficient use of clinical resources with patients experiencing long waits on multiple specialist lists in secondary care and sub-optimal polypharmacy management plans. Despite shared pillars of care for many for circulatory diseases.

This also exacerbates health inequalities for patients from deprived communities, who find it difficult and costly to attend multiple appointments in hospital. We are pioneering cross sector collaboration to support those with multiple LTCs.

What does your project aim to achieve?

We will optimise care for patients with LTCs by working differently to support their care across the whole care delivery system. We know that multidisciplinary team working has proven success in single specialty initiatives, but they are later in the patient journey and for single conditions.

We will supercharge integrated care by combined working across multiple specialties. This will start from early in the development of disease by identification at a practice level. Patients will then be managed by integrated teams that combine expertise from primary care, community healthcare trusts and secondary care providers. This will have unique ability to create our first ever LTC specialist clinicians.

Patients will have fewer appointments and local easy to reach access, to reducing health inequalities. It will enable accurate use of disease modifying therapies where there is a known benefit and avoid potential harmful interactions that develop from having conditions managed in isolation.

How will the project be delivered?

Our pilot will enable clinicians working together from primary, community, secondary care and voluntary sector, on a single shared care record with full access to patient notes that already exists in primary care but whose potential has not been exploited for this joined up care approach. This ensures a much more efficient interface and communication between these clinicians from different sectors and organisations. This approach will also enable more rich and comprehensive care plans for patients with their whole medical history being available in detail to these clinicians.

This approach does not need the purchasing of new IT systems, instead it is a more sustainable and scalable approach of using existing resources in a different way that supports a new model of care.

We will utilise a comprehensive ‘lean sigma’ approach to develop clear and measurable project goals, maximise limited resources and continually improve using learning from each delivery sprint.

How is your project going to share learning?

The clinicians are from across the whole care delivery system helping to provide champions to promote this new way of working in all sectors. We will utilise patient experts to support co-design.

The use of a shared care plan, agreed with and reviewed by the patient, with cross-specialty support in system delivery will put the patient with LTCs at the centre of their care. The teams involved are working as senior faculty  the BSol ICS, which has the most challenged socio-economic profile and structure. There is a commitment throughout ICS to develop this model such into the cross-organisation working that is being developed. This will provide learning and sharing opportunities to support patients and clinicians in the ICS.

We will share this work through local, regional, national platforms including open learning forums to support the development of the model. This offers a unique opportunity for individual and wider workforce development.