Long Term Conditions - RR

Long Term Conditions Strategy

Purpose of Paper :This paper reviews the literature, current measures in place to address long term conditions and activity data and defines the model that will be used to develop long term conditions for the future in Stockport and identifies the initial work programmes.

Human Rights Act, Disability Discrimination Act, Equal Opportunities Act Issues:

Health Benefit/Health Gain:Good management, starting from prevention of long term conditions, will improve health and reduce the burden of disease

NHS Plan, National Policy or HIMP Issues :

Good management of long term conditions is a national target area.

‘Sub Stockport’ Geographic or Population Group Issues:

Resource Implications:

As this is a strategy document there are no financial implications directly attributable to this document. There are a range of actions identified some are currently funded and identified as such. Other work plans will require the development of business cases to secure their funding.

Committees previously discussed or agreed at:

Committee LTC group Date 11th November SMCC board November PEC NovemberAction Requested:Members are asked to support this approach to the management of Long Term Conditions

Contact:Roger Roberts - 426 5570

Created by RRoberts Last printed 08/01/2008 8:48 AM 1

Board 28.1.08Item 8


December 2007

Contents

Long Term Conditions Strategy.......................................................................................................2Definition..................................................................................................................................2National Position......................................................................................................................2Principles for the Management of Long Term Conditions.......................................................3

Models of Care.............................................................................................................................5Stockport Long Term Condition Model of Care..........................................................................7Current Situation..........................................................................................................................8

Well population........................................................................................................................9At Risk population..................................................................................................................13Established disease.................................................................................................................15Developed disease..................................................................................................................17

DATA.........................................................................................................................................20SERVICE GAPS........................................................................................................................21

Well Population......................................................................................................................21At risk population...................................................................................................................22Established Disease................................................................................................................22Developed Disease.................................................................................................................24

Work programmes......................................................................................................................25Appendix 1 Strategy Development............................................................................................30Appendix 2 Needs Assessment..................................................................................................31



Introduction

Definition

A long term condition is any condition with which a person has to live for the remainder of their life. It may or may not be ultimately fatal. For the purposes of this paper Long Term Condition Management is defined as “a system of co-ordinated health care interventions and communications for populations with long term conditions in which patient self-care is significant”.

The needs of children are addressed in a separate review.

National Position

The DoH have issued their framework for the management of long term conditions in “Supporting People with Long Term Conditions” which lays out an NHS and Social Care model to support local innovation and integration. This clarifies the terminology for the different elements of care and sets a range of targets:

Focus initially on the very high intensive users of secondary care services through a case management approach.

Appoint community matrons to spearhead the case management drive. In total, there will be 3000 community matrons in post by March 2008.

Over time, develop a system of identifying prospective very high intensity users of services.

Establish multi-professional teams based in primary or community care with support of specialist advice to manage care across all settings.

Develop a local strategy to support comprehensive self care. Implement the Expert Patient Programme and other self care programmes. Take a systematic approach that links health, social care, patients and carers. Use the tools and techniques already available to start to make an impact.

The Public Health White Paper ‘Choosing Health’ underpins the entire long term condition approach. Also recently published are the papers titled “Supporting patients with long term conditions to Self Care” and “Our Health Our Care Our Say”. Both these papers build upon the theme of care for patients with long term conditions. The latest paper “Commissioning framework for health and well-being” confirms the issues in the earlier papers and promotes a way of health and social care commissioning for these services.

In each of the papers the messages are similar requiring choice for patients. To make this possible they have to have good information on a range of services available, near home, at times convenient to them. To do this it is repeatedly proposed that patients or their representatives are to be included in the planning of services.

To manage the increasing demand on services created by this approach self care is highlighted as key to helping patients manage their own conditions and prevent themselves becoming ill.

The scale of the problem


Seventeen and a half million people in this country report a long term condition (such as diabetes, asthma or arthritis). This is 82,000 in Stockport.

For some people, especially older people and those with more than one condition, discomfort and stress is an everyday reality.

The impact on the NHS and social care for supporting people with long term conditions is significant.

Care for many people with long term conditions has traditionally been reactive, unplanned and episodic. This has resulted in heavy use of secondary care services.

Just 5% of inpatients, many with a long term condition, account for 42% of all acute bed days.

The target There is a national target to reduce inpatient emergency bed days by 5% by March 2008

using 2003/04 as the baseline. In Greater Manchester this has been stretched to 6.4% Health communities are expected to make progress towards the target from 2005

onwards by offering a personalised care plan for vulnerable people most at risk. There are a range of recommendations within “Choosing Health”, “Our Health Our Care

Our Say” and the “Self Care” papers.

Although there is undoubtedly this large group of patients out there, we do not know which ones are the ones at risk of moving up from one level of care to another. Work is required to stratify people so that plans can be developed to address the specific needs of particular groups.

The Strategic Approach

Principles for the Management of Long Term Conditions.

The initial phase in the development of the strategy was the writing of a set of principles. These were consulted upon with a range of patient and carer groups. Further information on patient consultation is described in appendix 1.

These principles must be seen in the context of collaborative working between all partner organisations including health, local authority and the voluntary sector and working within the evidence base.

1. PreventionPeople at risk of long term conditions are identified and provided with support, advice and information to prevent or delay the onset of that condition. There is systematic risk factor screening and proactive support for patients requiring support in modifying their lifestyle.

2. Patient identificationPeople with disease will be sought to ensure that they are identified and appropriately treated. Prevalence data will be used to validate that appropriate levels of disease are identified. Stratification tools will be used to assist in segmenting the population to enable planning and provision of targeted services.

3. Person centred carePeople with a LTC are assessed personally taking into account the condition(s) they have with an aim to reduce the fragmentation of care. This includes a review of their social circumstances and, where indicated, a referral is made for carer review and welfare rights. A plan is developed with them, their family and carer and an annual reminder/review is arranged to update the plan if required.


4. Self carePatients with a LTC have a plan in place and are encouraged and supported in managing their own condition within the parameters they are able to manage and with triggers for when they then need to seek further support. A plan of how and what to offer in terms of information should be developed

5. Emergency and Acute ManagementPeople with an acute episode needing hospital admission or other acute provision for a LTC are treated in a timely manner by teams equipped to manage the possible multiple conditions that the person may experience besides the condition with which they are admitted. On admission to hospital good detailed information is supplied, where available, at the time of admission or as soon after admission as is possible. Where this is a planned referral high standard of referral information is supplied prior to the patient being seen.

6. Hospital DischargePatients with a LTC have a planned discharge and are discharged with appropriate support and understanding where they are in the management of their condition(s). Their plan is to be updated quickly on discharge to ensure their return to being self caring as soon as possible. This plan will be communicated quickly to all relevant people including carers and service givers. The plan should be written and a copy issued to the service givers and the patient/carer/family before discharge. The plan should contain contact details over 24hours to report any failure to deliver on the plan. A plan should be developed to meet shortfalls immediately as this may result in re-admission. A mechanism needs to be developed for individuals to measure the performance of the services received on this plan for forwarding to the commission(s)

7. RehabilitationPeople who have had an acute episode have access to appropriate rehabilitation and support to enable them to regain the maximum level of independence they are able to achieve and desire.

8. Provision of equipment People with a LTC are able to access the equipment and aids they require to lead as normal a life as possible.

9. Housing and accommodationThere should be sufficient access to the type of housing that is required to maintain independent living for as long as possible and as desired by the patient. This is outside the remit of the NHS.

10. Personal Care and SupportA person with a long term condition(s) should have access to information about their condition, information about the different means of support available to them and be involved in the processes deciding on the level of personal care required for them to maintain maximum choice about an independent life at home. A mechanism will be developed to assess the effectiveness and standards of this provision by the person/family /carer receiving the service(s)

11. Palliative CarePalliative care and general services are able to support those patients with a LTC who, as they approach the end of life, require specialist or more intensive support. They should have support in the management of symptoms, the relief of pain, meeting of personal needs, social and psychological and spiritual support.


12. Support for family and carersCarers of patients with a LTC are to have access to appropriate support and services that recognise their needs both in their role as carer and in their own right. The GPs will be expected to be able to demonstrate the patients in his/her practice with LTC by level of severity, the carers offering support to patients with LTC in the practice and the patients in the practice population who are carers of people outside the practice with LTCs.

The practice should have a plan of how to monitor these groups to ensure that they receive appropriate information and access to other professionals, relevant voluntary and self help organisations and educational courses with an aim to reduce deterioration and ensure maximum quality of life for the person with LTC’ and their families/carers.

The Proposed Model of CareThe model of care proposed is one described by the Australian Health Authorities for the management of long term conditions and is summarised in figure 2. It covers the well population and the prevention strategies that are required through to the population with active long term disease and the health care they require. It also highlights the importance of health promotion interventions in reducing movement from one sector to the next.

This model builds on the Kaiser Permanente model, figure 3 that is widely used in the NHS and provides a more comprehensive picture of the levels of intervention required. The three classifications used by the Kaiser model being Self Care, Care Management and Case Management. These apply to the established disease and controlled chronic disease sections of the Australian model only. The other two groups sit below the Kaiser triangle in the Health Promotion and Wellbeing section. It is therefore proposed that the two models taken together present a more complete picture.

The importance of the management of Health Promotion and wellbeing is further described in the Australian model as seen in figure 1. There is good evidence that factors including sense of control, social support/inclusion and early life factors are important in the development of wellbeing.

Figure 1 Health promotion


Figure 2 Australian Chronic Disease Model

Figure 3 Kaiser Permanente Model


Underpinned by Health Promotion and Wellbeing

Stockport Long Term Condition Model of Care

The model proposed for Stockport is based on the Australian model and is defined below. It is not very different to the UK model but promotes the area missing in the UK model – ‘prevention’. It outlines the areas of activity that relate to each level of care and approximate numbers of patients at each level.

Figure 4 The Stockport model

Well population At Risk population Established disease

Developed Disease

Prevention Prevention and detection

Disease management

Disease management

Promotion of healthy life styleSmokingDiet ExerciseAlcoholWell being

Screening Case findingRoutine health examinationEarly interventionRisk factor managementPatient empowerment

Disease managementSelf careMaintain risk factor reduction

Hospital admission / dischargeContinuing care Intermediate careCase managementPalliative care

Proportion of population (rough estimate only)210,000 75-85,000 5-10,000

As described the numbers of people with long term conditions or at risk of developing them is rising. One of the key factors has to be the empowerment of people to take charge of their own health and if a condition develops any condition they might have. There has been much review of the self management of patients and this is promoted as one of the key ways of reducing demand on services in the future. The WISE model below was published by the National Primary Care Research and Development Centre to address this issue.

Figure 5 The WISE modelPatient Professional Structure

Strategy Improve information Change professional response

Improve access to service

Specific method Work with patients to develop information that is Relevant Accessible Uses a combination

of lay and traditional evidence –based knowledge

Promote flexibility in professional response through A patient –centred

approach The negotiation of a

self-management plan with patients

Change access arrangements Use patient/professional

contacts as a means of complementing efforts in order to maximise the effectiveness of disease management

Allow patients to self refer based on self evaluation of need.


Patient Centred Care

One of the key issues is to integrate the elements of care and to develop a service that is patient centred.

In primary care there has been much work with the new GMS contract for GP practices to identify patients with, or at risk of, some conditions. Practices are then given incentives to provide specific evidence based interventions in the management of these conditions. The next step of development in the management of long term conditions is to integrate these interventions so that we are treating and empowering the patient and negotiating an agreed solution to their full range of conditions. Currently we may be managing diabetes, asthma and Parkinson’s disease at separate appointments for one patient confusing them with different sets of complex information and instruction.

Current Situation

IntroductionThere is considerable work already taking place in Stockport. The next section of the paper seeks to pull together these strands of service.

There are a range of common features in the management of any condition, the three middle features being from the Kaiser model, and these are the headings used in the next section of this paper. The other headings however are required to complete the continuum of care:

Prevention Patient Self care Disease management Case Management Palliative Care


Well populationPreventionPromotion of healthy life styleSmokingWeight management - Diet & ExerciseAlcoholWell being

Introduction Stockport has a wide range of primary prevention and health promotion programmes aimed at the common risk factors for key long term conditions and the social determinants of health. These include work streams around lifestyle issues such as physical activity, obesity, alcohol and substance misuse, tobacco use, mental wellbeing, sexual health and sustainable transport.

The PCT Public Health Directorate’s approach is to work in partnership with other agencies and, through the Local Area Agreement, to develop strong health alliances to provide a multifaceted response to the complexity of lifestyle influences on health.

Community servicesThe Health Visitor service provides support to many patients in the promotion of wellbeing commencing with support to new mothers. This is important in giving the children a good start in life and maximise their future health and the mental wellbeing of the parents.

The School nurses, with practice nurses deliver the immunisation service across Stockport. Practice nurses lead this work in children under school age and School nurses in the school age children. Healthy life styles are also promoted to young people in educational settings.

Pharmacy ServiceThe pharmacy is recognised in the new pharmacy contract as being a key site for the delivery of health promotion messages in both a campaign and targeted way.

Health inequalitiesThe prevalence of people living with long term conditions increases with levels of deprivation. Reducing inequalities in health is a key priority of the PCT. As part of the strategy to reduce health inequalities, the Public Health directorate has developed specifically designed interventions for the strategy’s 5 health priority areas i.e. major killers, CHD/cancer, tobacco, alcohol, obesity and mental wellbeing.

There are Community Development Workers providing support to particular groups who find services difficult to access e.g. Ethnic groups and women suffering domestic violence.

Promotion of Healthy Life stylea) Life course approachA whole life approach is used to address the common risk factors across all life stages: mothers and infants, younger people, adults and older people based on the evidence which suggests that the development of long term conditions is due to the effects of cumulative and interactive exposures. The Public Health directorate has strategic planning for each stage.


Mothers, infants, young people:The department contributes to the Children and Young People’s Strategic Plan with the aim for children in Stockport to be well cared for, healthy and able to make healthy choices. Programmes offered by the department include:

Projects to improve breastfeeding initiation rates, especially in areas of deprivation National Healthy Schools Programme: Collaborative working with education department,

local authority and private schools, school nurses on assisting Stockport schools to achieve Healthy Schools status as part of the national Healthy Schools Programme.

Dedicated health promotion adviser to address issues around childhood obesity. Breakfast club programme. The breakfast club initiative is focused on schools with 20%

or more free school entitlement. Development of healthy snack guidelines for staff working with under 12s Annual delivery of public health campaigns in various settings on breast feeding

awareness and increasing children’s intake of portions of fruit and vegetables. Specialist smoking cessation advisers linked to SureStart and maternity services. Dedicated health promotion adviser to address issues around substance misuse. Gathering of health intelligence to inform service developments – Young Peoples’

Lifestyle Survey being undertake autumn 2007 with results expected Spring 08. School travel plans

Adults and older people:This includes involvement with Stockport Health Improvement Partnership and the “ All Our Tomorrows” partnership for older people, which focus on issues that improve the quality of life for older people to enable them to live independently for as long as possible.

Programmes offered by the department include: Screening programmes: Breast and CVD Cancer awareness campaigns: skin, bowel and breast cancers Chlamydia screening is being developed Initiatives around weight management: Schemes in areas of deprivation: Fruit and

vegetable referral scheme. Delivering a programme of smoothie and cook and taste workshops.

Initiatives with Age Concern Promoting sexual health – Dedicated health promotion adviser providing support and

guidance to the PCT and other organisations on issues around sexual health. Promoting mental wellbeing. Dedicated health promotion adviser providing support and

guidance to the PCT and other organisations on issues around mental wellbeing. see supporting self care for other programmes

- Supported self care – Whole person approach To increase understanding of the different needs of different people in making sustained, healthier lifestyle choices, to enable the development of more effective services, the health promotion department is using social marketing techniques and is one of ten national pilot sites for this innovative approach.

To address the problem of individuals’ support being fragmented across different services the Public Health directorate is developing a “one stop shop” Lifestyle Service.


Promoting mental wellbeing/empowermentThe concept of wellbeing is important to the management and prevention of long term conditions. This concept is complex and made up of a wide range of factors. Where a person has a good sense of wellbeing they are more able to make lifestyle changes, cope themselves with minor disease or manage disease at levels above that of a person with a low sense of wellbeing.

Arts on Prescription Self Health at your library Health Defenders: promoting health literacy

Weight management Weight management and the reduction of obesity are key issues for the health service and are very relevant in Stockport.

Promoting physical activity Walking the Way to Health programme: short led walks aimed at people who have not

been active for some time or who have a health condition that would benefit from physical activity.

PARiS: A physical activity health professional referral scheme operating in areas of deprivation. COPD/Cardiac Rehabilitation patients are not geographically restricted.

Joint Strategic Needs Assessment 2007 indicated this is an area for further investment.

Interventions around obesity The Big Club: Closed exercise session for people with BMI of >30. “Keep it off for good”: 12 week support programme for people with waist measurement

34 inches and above ( women) 40”inches and above (men) A more comprehensive service is being developed

Smoking cessationA comprehensive, borough wide, smoking cessation service has been developed across 3 levels:

Intensive support from specialist core service staff for the most dependent smokers. This includes specialist provision for priority groups: pregnant women and routine or manual workers who smoke.

Intermediate services provided by trained staff in key settings Increasing numbers of health professionals and other relevant practitioners providing

brief opportunistic advice as a routine part of their daily duties, referring on where necessary to other parts of the service.

As tobacco use is a key driver in the development of health inequalities, there are additional services provided in areas of deprivation.

There is borough wide delivery of No Smoking Day campaign and it is identified as compulsory for all pharmacies to deliver this campaign as part of the public health element of their contract.

The team has also worked closely with the council supporting local businesses and residents to comply with the smoke free legislation


AlcoholThe department is part of the Safer Stockport Partnership which introduced measures to reduce alcohol related violence and anti social behaviour, contributing to the development of stronger communities.A public health campaign at Christmas targeted younger people with advice on staying safe and healthy during the party season.Alcohol education in schools was boosted with a new teachers’ support pack.

Sexual healthThe CASH service (Contraception and Sexual Health) provide prevention and support on sexual health issues.

Condom distribution service Delivering a number of health campaigns and events throughout the year which focused

on those experiencing the worst sexual health Increasing outreach services available via Central Youth Social marketing project on sexually transmitted infections and condom usage

commenced in priority one area (Brinnington).

Professional support Information service for health professionals Training offered on evidence base around lifestyle issues and supporting people to make

sustained healthier lifestyle choices


At Risk populationPrevention and detectionScreening Case finding and health examinationEarly interventionRisk factor managementPatient empowerment

Screening people at risk of disease

A number of interventions are supported in primary care by the QOF especially Smoking cessation and in the future obesity. Smoking cessation interventions are also delivered via the community pharmacy.

Stockport participates in all the national screening programmes listed below. These are important in the routine detection at an early stage when the chances of successful treatment are greatest.

Breast Cancer www.cancerscreening.nhs.uk/breastscreenBowel Cancer www.cancerscreening.nhs.uk/bowelCervical Cancer www.cancerscreening.nhs.uk/cervicalDiabetic Retinopathy www.nscretinopathy.org.ukDowns Syndrome www.nelh.nhs.uk/screening/dssp/

home.htmNewborn Bloodspots www.newbornscreening-bloodspot.org.ukNewborn Hearing www.nhsp.infoSickle Cell & Thalassaemia www.kcl-phs.org.uk/haemscreening

Routine Case Finding and Health Examination The GMS contract encourages practices to identify patients with a range of key diseases and then to list them for active evidence based management. Patients with hypertension are not in themselves ill but are at risk of other conditions, principally strokes. The QOF requires that these patients are monitored and their blood pressure is maintained within appropriate limits. Stockport runs an enhanced service to screen patients for increased risk of cardiovascular disease. All people over 35 years are invited for an appointment every five years to have their risk factors monitored e.g. blood pressure and cholesterol and managed when appropriate. In many practices there is a diabetes screen included in this appointment.

Early intervention when disease is detectedOnce identified with a risk factor out of range or an early presentation of disease patients are now coded with that condition on their medical record and enter a call and recall service to offer them evidence based care to manage this condition.


http://www.kcl-phs.org.uk/haemscreening

http://www.nhsp.info/

http://www.newbornscreening/

http://www.nelh/

http://www.nscretinopathy.org.uk/

http://www.cancerscreening/

http://www.cancerscreening.nhs.uk/bowel

http://www.cancerscreening/

Patient empowerment All interventions require delivery in the context of the person’s wider social situation. Experience from Case Management has shown that social isolation can cause people who would otherwise be able to cope at home to refer themselves to hospital. This is therefore an important issue for the Health Service and social isolation can not be identified as a Local Authority issue alone.

The new pharmacy contract supports self care, encouraging the purchase of medicines by patients to manage their own conditions. Locally this has been promoted through the development of a formulary to suggest the type of product to recommend in particular situations. The Pharmacy and surgery are encouraged to discuss this and agree the point at which the patient should be referred on to the surgery. This is being promoted through the GP/Pharmacy incentive schemes. The pharmacy contract also aims to integrate the provision of health promotion advice and signposting to other health services within the mainstream service. This is therefore open to all patients.

There is strong provision of services by the third sector in Stockport. An example of where this provision is important is in mental health where some of the smaller organisations offering services provided by local people are less threatening and therefore may be better received. Age Concern provides handy man and shopping services, and many others, to enable people to remain at home living an independent life. This sector will become really important in the support of people self caring.

The Public Health directorate delivers a number of programmes promoting and supporting self care e.g. Self Health @ your library.

Increasingly patients with mild to moderate depression are encouraged to manage the issue themselves by working through programmes either on their own computer or at the local library.

Risk factor management

The Public Health directorate contributes to provision of consistent lifestyle advice and therefore encourages people to manage their own health. Reinforcement of these messages at all levels of the system is provided through training and ongoing support to the specific screening programmes and commissioning the delivery of brief interventions for staff from all healthcare and partnership organisations, business and voluntary sectors.

A resource ‘Fit for Life’ covering the evidence base, relevant targets and practical actions staff can take to help patients in areas of lifestyle change has been developed for community staff.

A web based public health network has been created to support people in their public work.


Established diseaseDisease managementDisease managementSelf careMaintain risk factor reduction

Disease managementGMS contractThe quality and outcomes framework supports patients with established disease. The framework has driven a strong increase in the routine application of evidence based interventions in the management of patients with long term conditions. This requires GPs, Nurses and administration teams to work together to provide an efficient system.

The problem that has arisen in some practices is that it has led to a fragmentation of care as patients have their diabetes managed one day and may be back the next with their asthma and again with another condition. This does not promote patient centred care and can be very confusing for patients who may then get confusing and opposing messages. It may lead to patients who work not attending repeated appointments due to the difficulties in getting time off work. In some cases this is due to the skill set of the nurse seeing that patient, who is not qualified to address the other conditions the patient might present.

It is important that with the increase in numbers of patients with long term conditions that they are informed and involved in the decisions about what level of treatment they are going to undergo. In this way they are more understanding of their condition and able to manage better, calling on support later in the development of problems.

Stockport is an area committed to training of new professionals in both nursing and general practice. It is at the forefront of the development of these skills for the future. Most professionals would aim for the patient centred service above but find themselves constrained by the demands of service delivery. In some cases patients are not ready to become so much part of the decision making process. This is therefore an important issue to be addressed in the future.

Medication reviewThere is a medication review service for patients who are at risk of social isolation provided through the medicines management department in the PCT. Referrals are taken from district nurses, GPs, Social Work staff and Age Concern.

Pathway developmentCare Pathways are being developed in the hospital and community. They are being required as part of hospital contract specifications and will become important in Practice Based Commissioning contracts with other providers including provider services.

Mental HealthIn mental health there is currently a low level of service in primary care with access to CBT and other support limited. There are however graduate support workers and CPN services available.


Self CareThere is an Expert Patient Programme. This is small in scale at the moment when compared to the number of patients with long term conditions. This is open to all and patients can self refer.

Parallel to this are a range of disease specific courses being offered to patients. These include the Diabetes Xpert, pulmonary rehabilitation and cardiac rehabilitation. The diabetes course is open to all and accepts patient self referral, pulmonary rehab is only available on referral by the GP and cardiac rehab is only available for patient following an MI.

The Pharmacy has long been the centre for patients to purchase their own medicines. The range of medicines that are available has been increased by the department of health over the last few years to encourage this form of self management. A formulary for the management of some of the most common conditions has been circulated to pharmacists in Stockport, their staff offered training in accordance with the formulary and a trial undertaken to encourage patients to attend the pharmacy and not the surgery where they go with the single aim of getting a prescription to avoid having to pay for medication.

Maintain risk factor reductionThere are a number of secondary/tertiary prevention and health promotion programmes linked to disease specific care management. These are in partnership with other organisations i.e.

Phase IV Cardiac Rehabilitation Community Physical Activity FacilitatorThis scheme is designed to help reduce further CHD incidence by supporting the transition of patients from phase III to phase IV cardiac rehabilitation and assisting those individuals to achieve the targets in the CHD NSF. It focuses particularly on patients who have had an MI by providing information and opportunities for physical activity but also to make other lifestyle choices easier by signposting patients appropriately. The facilitator, in partnership with the Foundation Trust team, offers Sports Trust and Leisure Service staff opportunities to work with these patients, with the aim of increasing the patient choice of physical activity opportunities over the long term.

Take HeartCommunity based exercise class for people in Phase IV cardiac rehabilitation

Healthy Hospital The Public Health directorate is working in partnership with the Foundation Trust in developing a health promotion strategy in line with the WHO Healthy Hospital Programme and “standards for better health”.

Care pathways have been developed and are being piloted on inpatient wards for both smoking cessation and weight management, systematically helping staff identify and manage patients’ needs in these areas.

A further pathway is being developed to aid reductions in alcohol use.


Developed diseaseDisease managementHospital admission / dischargeContinuing care Intermediate careCase managementCarer support Palliative care

Continuing care There is a long established district nursing service providing support to many patients with long term conditions.

There is a well established Community Rehabilitation Service comprising domiciliary physiotherapy and occupational therapy whose aim is to promote independence for people often, though not exclusively, with long term conditions.

There are a number of groups of specialist nurses providing more specialist care for patients. Some of these work from the tier 2 service thus providing care at level 2 others work from a hospital base with consultants thus working at level 3. These teams include:

COPDDiabetesHeart FailureDermatologyPaediatrics (Hospital based service)

The Jointly funded community equipment service consists of the Wheelchair, Orthotic, Home Equipment Service and Independent Living Centre who work to support other services in preventing unnecessary hospital admissions and supporting patients on discharge from hospital.

Case managementStockport is in the forefront of work in Greater Manchester in the development of the case management service to support patients at level 3 as defined by the DoH in “Supporting People with Long Term Conditions”.

Intermediate careIntermediate care and the Rehabilitation at Home team provide up to 6 weeks of care to support long term condition patients through a crisis and aim to prevent admissions to hospital or facilitate a reduced length of hospital stay.

The Local Authority provides an intermediate care service to support people in their own homes or in a short term residential setting. The service can be provided to facilitate early discharge from hospital where the person is medically fit and is also used to prevent inappropriate hospital stays. In addition the service is used to prevent long term residential care admissions or facilitate discharge from such placements.


The service can support the patient during transition into a longer term placement either in their own home with a package of care or into a short term residential setting. This is a multidisciplinary team consisting of social workers, nurses, therapists and home support teams and it is managed by the local authorities’ adults social care department.

Hospital admission / dischargeThe discharge liaison nurse screens people throughout the hospital in order to identify those that require complex follow up support from the DN service and makes appropriate arrangements.

The Acute trust provides the Specialist Therapy and Rehabilitation (STAR) service this mainly supports younger head injury patients under 65yrs discharged from the Devonshire Unit.

The RRATHS (Rapid Response AT Home Service) service for over 65 patients is provided by the PCT and Local Authority to support people in their own home at a time of crisis.

The RAH (Rehabilitation At Home) and SHEDS (Stockport Hospital Enhanced Discharge Service) teams for patients over 65 years of age are jointly managed by the Foundation Trust, the PCT and Adult Social Care to facilitate early discharge from secondary care. These teams with the intermediate care services (not including the STAR team) are being formally pulled together into one coordinated service within the current older peoples service review.

Carer SupportIt is important to note that many people with long term conditions rely upon the support of an informal carer often a member of the family. Without the support of these people the care services would not mange the needs of the population needing care. It is therefore important that the needs of this group are also recognised and planned for in the future. In Stockport the Local Authority provides a lot of support for this group through the SignPost organisation. This is supported by the GP contract that asks practices to identify carers, noting this for inclusion in future consideration of their care needs and also encouraging them to make contact with the Local Authority for such support and any appropriate assessment.

There are situations where children become the cares of parents. These children will have some very specific individual needs above those of adults. It is even more important that these people are identified and appropriate support provided.

Palliative careThe Palliative care respite service provides support for carers looking after patients in the terminal phase of life. Patients access this service on referral by their GP.

The District Nursing teams with MacMillan and Palliative care teams provide support to patients approaching the end of life. This is being supported by the care of the dying care pathway and the community pharmacy supply service for the medication. Services are delivered in partnership with the LA


Social supportExperience from Case Management has shown poor mental wellbeing, often secondary to social isolation, can cause people who would otherwise be able to cope at home to refer themselves to hospital. This is therefore an important issue for the Health Service and must be addressed by all partners who commission and provide services to the people of Stockport. Data would suggest that we have a high population of people living alone in the UK and that this will become increasingly important.

The Local Authority commission, and provide, a wide range of services; home care, Social Work teams including hospital discharge social workers, meals on wheels, etc. A newer element of service is Care Call, part of Stockport Homes. Commissioned by adult services they provide telecare in conjunction with their existing vital call service. The vital call service is the button worn around the neck that can be used to summon help in the event of a fall or other problem. The telecare call system is where sensors are placed about the patient’s home. The call centre would be alerted if the patient got up in the night and did not return to bed after a reasonable time. The suspicion might be that the person had fallen. The aim of the service is to give the person the confidence to remain at home.

Other elements of the Local Authority are also important in the maintenance of good health or reducing poor health. Housing is crucial to the wellbeing of the population. Ensuring high standards of housing will, for example, reduce damp that aggravates asthma; good insulation will reduce the cost of heating and ensure that elderly people do not develop hypothermia in cold winters. The development of Specialist provision in the form of sheltered housing and extra care housing are also important to patients maintaining their independence. Extra care housing is a big development area for Stockport in the coming few years.

Debt is also an important factor for people and can lead to poor health, especially depression. The Local Authority has a vital role in the provision of these services and publicity of them to appropriate sections of the population.

For older people who do not meet Fair Access to Care Criteria for a service from the Local Authority Age Concern are funded by the Local Authority to provide a service (Wellcheck) to assess the needs of the person and local services available to meet them. There is a strong third sector provision in Stockport although coordination of these with the statutory services could be improved.


DATA

A full needs assessment has been undertaken for long term conditions and is included in the appendix.

This assessment confirms the large number of patients in Stockport reporting a long term condition that limits in some way their way of life. This was reported in the 2005 General Household Survey as 43,000 people over 16 and in the 2005 Health Survey for England 34,000 people over 65. The numbers of people with these limiting conditions increases with age and is higher in males in middle age moving to females in older age. There is a good match between the areas with higher levels of deprivation and areas with higher levels of reported disease that limits activity.

The data on diseases experienced by people in Stockport is detailed in the needs assessment (Appendix 2). The needs assessment figure 3.1 shows the numbers of people with each condition, fig 4.1 the top conditions causing hospital admissions and fig 4.2 data on the ambulatory care conditions. These are presented in descending order of the top 10 conditions in each group in the following table.

Most frequent conditions Conditions causing admissionAmbulatory care

admissions1 Hypertension Chronic Heart Disease Dental2 Asthma Chronic Obstructive Pulmonary

DiseaseENT

3 Chronic Heart Disease Diabetes Angina4 Diabetes Stroke Chronic Obstructive

Pulmonary Disease5 Thyroid Heart Failure Flu/Pneumonia6 Stroke Asthma Epilepsy/convulsion7 Chronic Kidney Disease Chronic Kidney Disease Dehydration & GI8 Chronic Obstructive

Pulmonary DiseaseHypertension Diabetes

9 Atrial Fibrillation Thyroid Heart Failure10 Heart Failure Atrial Fibrillation Cellulitis

From this data the top ambulatory conditions identified in Stockport that require attention are: Diabetes Epilepsy Flu and dehydration Chronic Obstructive Pulmonary Disease Cardiovascular Disease

These are therefore top priority for review and development


SERVICE GAPS

There are a range of areas where there is work planned and under way. The strategy in no way wishes to stop or delay this activity and in this section sign posts to where this work is being undertaken. There are other areas where work is required and these are identified for future consideration of the appropriate lead person. Future papers will be required to pick up these elements of work and further develop the strategy.

The conditions listed above as being those that are top priority for Stockport are considered in each of the sections below. In many cases the service developments will be more generic than specific to the area identified but will contribute to the management of that service. The areas of the Australian model are used in the next section.

Well PopulationPublic Health is undertaking a service review and will assess the services available against the population needs. This will be reflected in the joint strategic needs assessment on which public health are taking the lead. Early areas of identified need for development are:

Alcohol brief intervention service Lifestyle service Weight management strategy Health trainer project – initially linked to weight management project

It must be noted that the investment criteria of “invest to save” are very difficult to apply to prevention interventions. Though prevention potentially creates massive savings they will not be evident for many years and are rarely able to be credited to the intervention made.

Wellbeing The main elements of wellbeing are: Keeping physically active Eating well Drinking in moderation Valuing yourself and others Talking about your feelings Keeping in touch with friends and loved ones Caring for others Getting involved and making a contribution Learning new skills Doing something creative Taking a break Asking for help.

It is important that these become more widely understood and are considered in the development of new and reviewed services. Currently there is work ongoing in this area in support of mental health services but to be fully effective this needs to become a more explicit part of service development in many areas and not become stigmatised as being mental health.


At risk populationThere are gaps in service in relation to a number of aspects in this area.

Case findingCase finding is incentivised through the Quality and Outcomes Framework (QOF) however there are a number of conditions not included in the QOF. These are not therefore receiving the same focus of attention. This is not the case with the priority disease areas

Disease PrevalenceThere is a wide variation in prevalence across practices within any disease area in the QOF and this requires review to ensure that this is a justified variation. This is key in the management of the priority disease areas.

ScreeningScreening is usually well taken up in Stockport but there are health inequality access issues to be addressed in relation to these services. Screening programmes are in place in accordance with national criteria. They are however developing and expanding. The introduction of a bowel screening programme is planned and the introduction of the HPV vaccine will alter the cervical screening programme in some years’ time.

Social IsolationSocial isolation can be significant as people become older and less able to travel. Schemes such as befriending schemes and the Gerbera scheme would significantly support this element of care. The Extra Care Housing developments proposed in Stockport will be important in addressing this element of care. This underpins the management of all disease and will be equally important to the management of the priority disease areas.

The Carecall and telecare systems are developing and the local authority has a target to provide 750 service users with vital call alarms and other additional technology aimed at promoting independent living. This service needs to be developed with associated telehealth and the Carecall call centre developed with a plan to commission a joint service in the future. Consideration must be given to how the Carecall, Mastercall and BUPA call centres are integrated in the future to provide a single comprehensive service

We need to explore the potential for stand alone telecare systems for informal carers.Adults social care fund a variety of services in conjunction with colleagues from the third sector aimed at providing practical preventative and low level support to help alleviate social isolation

Established DiseaseFor established disease and controlled chronic disease there is significant service in place however this can be uncoordinated.

Care PathwaysCare pathways are required to improve the level of integration of service. Care pathways however potentially increase the disease specific approach to health care as opposed to the


patient centred approach promoted in the DoH framework. There is a need to negotiate a care plan with a patient that covers their spectrum of disease. They should not for example be given a plan for their asthma, angina and Parkinson’s disease separately. For the priority disease areas this is important as there will be many other conditions experienced by people with the priority diseases and they must be managed in the context of the wider health need.

Patient EmpowermentPatients need to become more empowered to manage their own care and the expert patient programme is well established in Stockport. This requires further development to get better attendance from all groups of the population. However the programme in place has recently doubled its capacity.

In addition to this the early stages of disease specific education are emerging with the requirement by NICE to have education in place for new patients with type II diabetes. This approach to group teaching has also been used for cardiovascular management after a heart attack. In primary care this approach was tried for routine lipid management and anecdotally it did not create change at the time but caused some of the more resistant patients to return for a consultation to ask for treatment they had not previously taken. As the numbers of patients with conditions increase more of this group management will be required.

More patient education must therefore be commissioned to support both the generic expert patient programme and the disease specific programmes for the more common conditions. This is required in both the extension of current programmes and the development of further programmes for other conditions.

Patient Centred CareTo make patient care patient centred a negotiated care plan is required. Most health professionals would say that this is what they aspire to achieve. Patients do not recognise this as the outcome of consultations and may not be ready for this style of approach. Work is therefore required on the style of consultation and the preparation of the patient for this type of discussion that would culminate in a written care plan with which they are willing and able to comply. This is being incentivised through the PBC incentive scheme but still requires significant development to become routinely used.

Multi-professional WorkingTo manage the numbers of people with LTC all members of the wider teams will need to play their part. One of these is the community pharmacist. In this setting the patient should be able to access the medication they require to manage most minor self limiting conditions without access to the doctor. This access is used less these days as patients have been trained that there might be something serious behind their symptoms and they need a doctor. There are also social pressures to access sick notes from the doctor. There has also been a reduction in public knowledge about how to manage many conditions themselves.

Brief interventions to address lifestyle issues can often be made by a fellow member of the local community working in the pharmacy and with smoking cessation this has shown to be at least as effective as the message from the surgery. The pharmacy can also undertake low level medication reviews. In the future they will manage more often repeat medication for patients with stable conditions as repeat dispensing becomes available. This development is addressed in the PCT medicines management development plan.

This will be important in the management of the priority conditions as well as many others.


Developed Disease

Case ManagementThe targets set out in the DoH framework for the management of long term conditions, “Supporting people with Long Term Conditions”, are being addressed. The first three targets relate to the provision of the Active Case Management service and there are case managers in post with case loads developed from the PARR and Castlefield scoring systems to identify the high or potentially high intensity service users. There are services in place to manage patients with complex needs in a multi-professional way but this requires wider development. This service will support people with a wide range of conditions including the priority conditions identified. As one of the criteria is the number of patients with that disease this service will support many of the most severe patients with the priority conditions.

Service Reviews.There are major service reviews taking place in Older Peoples service and Primary Care Mental Health services. These will contribute to this agenda significantly and this strategy will influence their development. It is also planned to review a number of services as defined in the 2007/8 business plan.

Cardiology Stroke Services IVF ServicesPhysiotherapyCVD Screening Maternity Services GP input into Nursing Homes Salaried dental service

Podiatry Service.Health Visiting & School Nursing District, ACM and Treatment Room NursingGP Out of Hours Contract Palliative Care Review End of Life Services Voluntary Services Limb fitting and support centre

TelehealthStockport Local Authority received funding from Central Government to fund telecare projects that are currently in place and expanding. There is a need to consider the opportunity to develop joint services linking in telehealth interventions. Telehealth would enable the patient to take a blood pressure, ECG or similar test and feed the results down a telephone line to the centre to ensure that all is well with their long term condition. There are also medication aids that can be linked to these systems that would identify if a person had taken their medication and remind them to do so.

A call centre can however do much more in assisting the patient in their journey down a care pathway. Once a pathway is agreed the call centre can pilot the person reminding them at appropriate times to do things. Where a professional has established an individual plan for a patient the call centre can provide the follow up to ensure that this has been understood and is being implemented. Some development work is going on in Stockport on this type of intervention. This in time will need to link to the telehealth and telecare services described above.


Case management has been established in Stockport. The learning from this has been useful and is being used to review the District Nursing Service. The approach of completing a detailed review of the person and their needs and addressing all needs including social needs has proved to be a good model. It is proposed to make this the outline for the District Nursing Service in the future and to move away from the task specific focus of recent times. Work is also planned to further integrate the work of the Health and Social Care teams to deliver the packages of need identified. This development will be of generic benefit to the priority conditions.

Palliative CareAt the end of life the current level of palliative care is limited and largely focused around cancer patients. This is recognised and plans are in place for it to become more widely applicable to include other conditions such as COPD and heart failure. The place of death is currently usually in hospital or in older age groups in care homes. Patients express the desire for this to more often be in their own home. There is significant work in place to develop the end of life pathway according to the GOLD standards and the Liverpool pathway. This development is described in the palliative care team’s action plan.

Work programmesFrom the above description it can be seen there are a number of work plans already in place and these will continue. The details of these plans are contained in specific papers on these developments and will come through the relevant committees as they reach an appropriate stage of development.


Project Evidence base

Call Centre Approximately 26 trials have reviewed telephone support services and in broad conclusion they have improved outcomes and when used post discharge have reduced reliance on other health care services

Telehealth There have been over 30 trials looking at telehealth and where coupled with telephone follow up with a clinician was most positive

Health trainers Health Trainers are required by “Choosing Health” public health white paper. The intervention is based on a wide range of behaviour change research.

LTC Enhanced Service This service is about better understanding the population and their level of risk to support future planning. When used to support service development the evidence is good for this work.There is also a simple intuitive targeting of activity to put in place plans to reduce avoidable hospital admissions. There is little evidence either way on the outcomes of such an approach

Case Management The evidence for case management came from the States and has not been matched in the UK where the same model has been applied. In Manchester the model has been developed and there is some positive evidence for care in patients homes and provided by an integrated team that would indicate success.

Personalised Care Plans There is little evidence that these used alone are beneficial

Medication Review There is little evidence in this area but this workstream is about getting the best from the QOF and Pharmacy contracts to do this work. Locally where reviews have been done well they have saved the cost of the review at least twice.

Patient Education There is evidence that patient education may move care from hospital to primary care

Palliative Care Being developed to support the delivery of the Gold Standards Framework.

Mental Health The Stockport developments are required by the Mental Health NSF and delivery of key targets.

Project Description Place of delivery Lead TimescaleResources

Call Centre Pilot call centre with BUPA. Patients with 8 major conditions will be supported over and above normal care through the call centre

To be delivered to a population of 10,000 patients through approx 12 practices

Jane Rossini & Roger Roberts

6month pilot commence August 2007

Pilot funded until May 2008. Further funding is being considered by SMC to maintain pilot until end of March 2009 when the success of the pilot can be established. Estimated unconfirmed cost £135,000

Telehealth Companion project to support medication taking

COPD telehealth project pilot

ECG done in practice and interpreted by phone

Pre-consultation questionnaires

To be piloted with 20 machines

Join PCT Mastercall pilot

Enhanced Service

Pilot

Roger Roberts 12 month pilot commence January 2008

6 month pilot commence February 2008

Pilot complete and service ready

Pilot for 12 months commence Jan 2008

Pilot funded by LA assistive technology budget. Rollout to be reviewed on basis of pilot.

Joint funding PCT slippage and Mastercall

Enhanced services

Slippage funding


Health trainers

Prevention initiative providing 1 to 1 behaviour change support targeting a) Clients aged 40-65 who are sub threshold for chronic diseaseb) Clients who are overweight or obese as part of the weight management ICAT

21 most deprived practices

Clients referred into weight management ICAT

Jane Pilkington Contract let to provide December 2008

Money identified in LDP

LTC Enhanced Service

To stratify patients over 65 years of age and develop capacity in primary care to manage patients at the stage before ACM to prevent onward development

To be piloted in two PBC localities

Roger Roberts Sept 07 – Oct 09

LES funded for 2 localities initially.

Case Management

Intensive support for patients with multiple needs that might otherwise lead to hospital admission

Available to all practices Clare Watson Currently in place and developing

Funding identified in LDP

Personalised Care Plans

PBC incentive scheme requires practices to develop personal care plans for patients. Standard templates are being developed

Delivered to all practices via incentive scheme

Roger Roberts Financial year 2007/8

Incentive scheme funding identified

Medication Review

Medication review is required by QOF and improvement in standard will improve reduction of medication waste. Patients taking 4 or more meds will have to have this face to face. Links with pharmacy MUR will assist in management of volume

Delivered in small number of pilot practices in 2007/8

Roger Roberts Financial year 2007/8

No funding required as done within contract frameworks


Patient Education

Expert Patient – Programme encourages patients with any condition to manage their own careDisease specific patient training for:Diabetes – Xpert programme

COPD – pulmonary rehab

Obesity – Keep it off for good- Slimming World

Asthma

Open to patients from any practice

Trialled and opening up to all in 2007/8

Via tier 2 service

Delivered through public health To be commissioned

Fran Holmes

Tracy Hancock

Karen Fern

Gill Dickinson

Roger Roberts

On going and expanded in 2007/8

Pilot complete and rollout Sept 07

Ongoing to expand in 2009/10On goingTo be piloted in 2007To develop in 2008/9

Funding identified

To be commissioned and funding required LPD bid being developed

Funding to be identifiedFunding identified

Palliative Care

Palliative care strategy is being developed This will have a number of associated work streams

Jointly across primary and secondary care.

Dr David Waterman

December 2007 To be identified through palliative care strategy

Mental Health Review of the primary care mental health service

PCT review Gina Evans Implementation 2008

Identified in LDP

Older People There is a major service review of older peoples services underway leading from the review of Cherry Tree services and this links very strongly with the provision of long term conditions services for this group of patients. The detail of this review is however addressed in other papers. This work stream is led by Maggie Keufeldt

Appendix 1

Strategy Development Public ConsultationThis strategy has been developed with the inclusion of the views of patients in Stockport. The principles were circulated to a range of patient groups that represent patients with long term conditions and they were asked to comment on these. They were further invited to report the three top issues for them under each principle area and these have been built into the action plan where possible.

There was little response to this communication and the comments received are available for view.

The strategy has now been circulated for further discussion and a group will be established to monitor the action plan development for the range of projects in the strategy and serve as a reference group for the project leads.

Appendix 2

Long-term Conditions – Needs Assessment

1. Introduction

Whilst there is no definitive source of information about the number of people in Stockport who have a long-term condition there is a range of evidence we can use to estimate the prevalence of these conditions and likely trends over time. This process however, is complicated by the fact that there are many different long-term conditions, some of which co-exist within the same patient, and that there are varying degrees of evidence for each condition as to the extent of the problem within Stockport.

2. Overall Prevalence2.1. Overall prevalenceNational evidence presented within the NSF for long-term conditions suggest that 17.5 million people in the United Kingdom (approximately 30% of the total population) live with a long-term condition; by the time people reach the age of 75 the proportion increases to over three-quarters (DH 2001). If extrapolated to Stockport these national figures suggest that around 82,000 people in the borough have a chronic health problem of who over 17,000 people are aged 75 years or above.

Other sources of evidence for the overall prevalence of long-term conditions within the population are severely limited and therefore the subsequent analysis relies on proxy measures. The 2005 Health Survey for England, which concentrated on the health of those aged 65 years and above; stated that “longstanding illness is an important indicator of the general health of the population. It indicates need for health and social services” however the report notes that “it is important to remember that data based on the informants’ subjective view may not necessarily correspond to medical diagnoses...[indeed] there is evidence that people rate their health in different ways: some think in terms of health behaviours or physical functioning and others consider specific chronic health problems such as diabetes that affect morbidity. There are also marked differences in the assessment of health between the sexes.” Despite these warnings it is one of the few useful and comprehensive measures of health status available at the local level.

Evidence from the Welsh Health Survey 2003/04 suggests that levels of limiting long-term illness are lower than reported levels of chronic conditions at all ages, and although the data from this survey cannot be directly applied to Stockport the general implication of the trend, i.e. that reports of limiting long-term illness are likely to underestimate the prevalence of chronic conditions, should be borne in mind with the following analysis.

The 2005 General Household Survey, which focuses on people in Great Britain who are aged 16 years and above, asked people to report whether they had a long-standing condition, and whether or not any condition limited their day to day activities. 33% of respondents stated that they had a long-term condition, and 19% reported that they lived with a limiting condition; extrapolating these figures to Stockport this gives estimates of 75,000 people aged 16 plus with a longstanding condition and 43,000 people aged 16 plus whose condition limits their lives.

The results of the 2005 Health Survey for England shows that both men and women aged 65 and over reported the same prevalence of limiting longstanding illness or 71%, extrapolating to

Stockport this equates to around 34,000 people aged 65 and over, and 42% of men and 46% of women reported that their illness limited their activities in some way; approximately 20,000 people aged 65 plus locally. The prevalence of longstanding illness and limiting longstanding illness increased with age in both sexes (see section 2.2) and the prevalence of self-reported longstanding illness and limiting longstanding illness was lower among informants with higher income (see section 2.4). The Health Survey for England however does not provide comprehensive data for those aged under 65 years of age nor is it reliable at the local area level.

The 2001 Census of Population was the most recent comprehensive survey conducted within Stockport which posed questions about long-standing illness in the borough. Results showed that 17.7% of the resident population of Stockport (50,300 people) described themselves as having a long-term illness which limited their day-to-day activities; a number which is well below the estimate of 82,000 outlined above but much closer to the estimate from the General Household Survey of those with limiting illness. Unsurprisingly rates are much higher for those in communal establishments (87.2%) as compared to household residents (17.1%), although only around 2,000 of the total population are reported to live in these institutions. Further in-depth analysis of the 2001 Census results by age, gender and deprivation is presented in sections 2.2 to 2.4 below.

2.2. Overall prevalence by ageOlder people make up an increasing proportion of our population. Nationally since the early 1930s, the number of people aged over 65 years has more than doubled and is continuing to rise. In Stockport in 2001, 16.6% of the population were aged 65 and over; this is forecast to rise to 18.1% by 2011, with a projected increase of more than 1,000 people aged 85 plus over the decade. Although average life expectancy is increasing in the borough, improvements in mortality may not necessarily be reflected by improvements in morbidity. These changes in population characteristics could lead to increased demand on health services, especially if age specific prevalence of morbidity described below remains constant or increases while the number of older people rises.

Figure 2.1: 2001 Census of Population - Limiting Long-term Illness

3.0%4.6% 4.4% 4.5%

6.1% 6.6% 7.6%9.3%

11.6%14.3%

18.8%

25.4%

32.4%

36.6%

42.7%

53.4%

63.9%

72.4%

81.9%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90+

Age Group

Pro

po

rtio

n r

ep

ort

ing

a L

LT

I

The 2001 Census showed that prevalence of limiting long-term illness within Stockport increased sharply with age, with over 75% of those aged 85 years and above reporting having such a condition (see figure 2.1), again rates for residents of communal establishments were much higher than those of household residents (93.1% and 72.% respectively).

However although the prevalence of limiting long-term illness followed an age profile it is worth noting that of the 50,300 people with a limiting long-term illness only 4,200 (8.3%) were aged over 85 years due to the low population size at this age (see figure 2.2). The majority of people with limiting long term illnesses were aged between 60 and 79 years, around 20,000 people or 40% of the total.

At the other extreme of the age scale around 3,000 children and young people aged under 20 years and 2,000 people in their 20s in Stockport were identified as living with a limiting long-term illness (see figure 2.2).


488

827 863759 804

1,105

1,683

2,137

2,354

2,693

3,903

4,221

4,814 4,820

5,0925,254

4,076

2,725

1,455

0

1,000

2,000

3,000

4,000

5,000

6,000

0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90+

Age Group

Peo

ple

rep

ort

ing

a L

LT

I

2.3. Overall prevalence by gender54.7% of those reporting a limiting long-term illness were female, a figure slightly higher than the average population split of 51.7% but reflecting the greater longevity of women. For similar reasons females reported a higher overall rate of limiting long-term illness than males (18.6% and 16.5% respectively) and both males and females followed an age profile of increasing levels of illness (see figure 2.3). Similar proportions of both genders experienced illness at ages under 60 years; however during ages between 60 and 69 years males are more likely to report a limiting condition than females. For those in their 70s the rates are again comparable between men and women however once over the age of 80 years females are more likely to live with a limiting illness, indeed for those aged 90 and over 83.1% of women reported a limiting condition compared to only 76.9% of men.


4.6% 4.7%6.3%

8.8%

12.8%

21.2%

36.7%

47.7%

62.0%

76.9%

3.0%4.2%

6.4%8.1%

13.0%

22.2%

32.2%

47.5%

69.5%

83.1%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90+

Age Group

Pro

po

rtio

n r

epo

rtin

g a

LL

TI

MALES FEMALES

2.4. Overall prevalence by area and deprivationGeographical evidence suggests that rates of limiting long-term illness increase as deprivation levels rise, despite the fact that deprived areas tend to have younger populations. Figure 2.4 shows the distribution of concentrations of limiting long-term illness across the borough as reported in the 2001 Census. Areas that have levels of illness more than 50% higher than the local average include Brinnington, Lancashire Hill, City Villages, Councillor Lane, Offerton Estate, Woodley and Hawk Green; the majority of these areas rank amongst the most deprived areas of Stockport.

HealdHealdHealdHealdHealdHealdHealdHealdHealdGreenGreenGreenGreenGreenGreenGreenGreenGreen

GatleyGatleyGatleyGatleyGatleyGatleyGatleyGatleyGatleyCheadleCheadleCheadleCheadleCheadleCheadleCheadleCheadleCheadle

Heaton MerseyHeaton MerseyHeaton MerseyHeaton MerseyHeaton MerseyHeaton MerseyHeaton MerseyHeaton MerseyHeaton Mersey

HeatonHeatonHeatonHeatonHeatonHeatonHeatonHeatonHeatonMoorMoorMoorMoorMoorMoorMoorMoorMoor

BridgehallBridgehallBridgehallBridgehallBridgehallBridgehallBridgehallBridgehallBridgehall

CheadleCheadleCheadleCheadleCheadleCheadleCheadleCheadleCheadleHeathHeathHeathHeathHeathHeathHeathHeathHeath

CheadleCheadleCheadleCheadleCheadleCheadleCheadleCheadleCheadleHulmeHulmeHulmeHulmeHulmeHulmeHulmeHulmeHulme

AdswoodAdswoodAdswoodAdswoodAdswoodAdswoodAdswoodAdswoodAdswood

EdgeleyEdgeleyEdgeleyEdgeleyEdgeleyEdgeleyEdgeleyEdgeleyEdgeleyShawShawShawShawShawShawShawShawShawHeathHeathHeathHeathHeathHeathHeathHeathHeath

NorthNorthNorthNorthNorthNorthNorthNorthNorthReddishReddishReddishReddishReddishReddishReddishReddishReddish

HeatonHeatonHeatonHeatonHeatonHeatonHeatonHeatonHeatonChapelChapelChapelChapelChapelChapelChapelChapelChapel

HeatonHeatonHeatonHeatonHeatonHeatonHeatonHeatonHeatonNorrisNorrisNorrisNorrisNorrisNorrisNorrisNorrisNorris

ReddishReddishReddishReddishReddishReddishReddishReddishReddish

SouthSouthSouthSouthSouthSouthSouthSouthSouthReddishReddishReddishReddishReddishReddishReddishReddishReddish

BramhallBramhallBramhallBramhallBramhallBramhallBramhallBramhallBramhall

WoodfordWoodfordWoodfordWoodfordWoodfordWoodfordWoodfordWoodfordWoodford

HeavileyHeavileyHeavileyHeavileyHeavileyHeavileyHeavileyHeavileyHeaviley

Mile EndMile EndMile EndMile EndMile EndMile EndMile EndMile EndMile EndCaleCaleCaleCaleCaleCaleCaleCaleCaleGreenGreenGreenGreenGreenGreenGreenGreenGreen

BramhallBramhallBramhallBramhallBramhallBramhallBramhallBramhallBramhallGreenGreenGreenGreenGreenGreenGreenGreenGreen

DavenportDavenportDavenportDavenportDavenportDavenportDavenportDavenportDavenport

WoodsmoorWoodsmoorWoodsmoorWoodsmoorWoodsmoorWoodsmoorWoodsmoorWoodsmoorWoodsmoor

LancashireLancashireLancashireLancashireLancashireLancashireLancashireLancashireLancashireHillHillHillHillHillHillHillHillHill

BrinningtonBrinningtonBrinningtonBrinningtonBrinningtonBrinningtonBrinningtonBrinningtonBrinningtonWoodleyWoodleyWoodleyWoodleyWoodleyWoodleyWoodleyWoodleyWoodley

BredburyBredburyBredburyBredburyBredburyBredburyBredburyBredburyBredbury

BredburyBredburyBredburyBredburyBredburyBredburyBredburyBredburyBredburyGreenGreenGreenGreenGreenGreenGreenGreenGreenCentreCentreCentreCentreCentreCentreCentreCentreCentre

GreatGreatGreatGreatGreatGreatGreatGreatGreatMoorMoorMoorMoorMoorMoorMoorMoorMoor

OffertonOffertonOffertonOffertonOffertonOffertonOffertonOffertonOfferton

HazelHazelHazelHazelHazelHazelHazelHazelHazelGroveGroveGroveGroveGroveGroveGroveGroveGrove

HighHighHighHighHighHighHighHighHighLaneLaneLaneLaneLaneLaneLaneLaneLane

StrinesStrinesStrinesStrinesStrinesStrinesStrinesStrinesStrines

MarpleMarpleMarpleMarpleMarpleMarpleMarpleMarpleMarpleBridgeBridgeBridgeBridgeBridgeBridgeBridgeBridgeBridge

MellorMellorMellorMellorMellorMellorMellorMellorMellorOffertonOffertonOffertonOffertonOffertonOffertonOffertonOffertonOffertonGreenGreenGreenGreenGreenGreenGreenGreenGreen

MarpleMarpleMarpleMarpleMarpleMarpleMarpleMarpleMarple

HawkHawkHawkHawkHawkHawkHawkHawkHawkGreenGreenGreenGreenGreenGreenGreenGreenGreen

RomileyRomileyRomileyRomileyRomileyRomileyRomileyRomileyRomiley

CherryCherryCherryCherryCherryCherryCherryCherryCherryTreeTreeTreeTreeTreeTreeTreeTreeTree

CompstallCompstallCompstallCompstallCompstallCompstallCompstallCompstallCompstall

CoteCoteCoteCoteCoteCoteCoteCoteCoteGreenGreenGreenGreenGreenGreenGreenGreenGreen

Figure 2.4: 2001 Census of PopulationLimiting long-term illness

This map has been reproduced with the kind permission of Ordnance Survey on behalf of The Controller of Her Majesty's Stationery Office.Crown Copyright. Unauthorised reproduction infringes Crown Copyright and may lead to prosecution or civil proceedings. All Rights Reserved. HA100005991 Stockport PCT 2004.

Lower Super Output Area

More than 50% above Stockport average (9)25% to 50% above Stockport average (16)

1% to 25% above Stockport average (44)Below Stockport average (17.68%) (121)

Source: 2001 Census of Population, Office for National StatisticsSource: 2001 Census of Population, Office for National Statistics

Evidence from the 2001 Census suggests that the five most deprived wards in the borough contain a quarter of those with limiting long-term illnesses, despite having a total population share closer to 20% and a much younger age profile than the more affluent areas. The 2001 ward of Brinnington had the highest rate of limiting long-term illness, a quarter of the population in this area reported having such a condition.

The 2004 Index of Multiple brought together many different sources of information to build a comprehensive picture of deprivation across the country. One of the key indicators within the health domain was the ‘comparative illness and disability indicator’ which presented age and sex standardised data relating to the uptake of various types of financial benefits available to those living with long-term illness and disability. Figure 2.5 shows the pattern of uptake of these benefits across Stockport and again the distribution follows closely patterns of known deprivation. The ‘priority 1’ areas of Brinnington, Lancashire Hill and Adswood and Bridgehall are all identified as having levels of uptake more than 25% above the England average, as are other areas of deprivation such as Reddish, Offerton Estate, Edgeley, Shaw Heath and Bredbury.

HealdHealdHealdHealdHealdHealdHealdHealdHealdGreenGreenGreenGreenGreenGreenGreenGreenGreen

GatleyGatleyGatleyGatleyGatleyGatleyGatleyGatleyGatleyCheadleCheadleCheadleCheadleCheadleCheadleCheadleCheadleCheadle

Heaton MerseyHeaton MerseyHeaton MerseyHeaton MerseyHeaton MerseyHeaton MerseyHeaton MerseyHeaton MerseyHeaton Mersey

HeatonHeatonHeatonHeatonHeatonHeatonHeatonHeatonHeatonMoorMoorMoorMoorMoorMoorMoorMoorMoor

BridgehallBridgehallBridgehallBridgehallBridgehallBridgehallBridgehallBridgehallBridgehall

CheadleCheadleCheadleCheadleCheadleCheadleCheadleCheadleCheadleHeathHeathHeathHeathHeathHeathHeathHeathHeath

CheadleCheadleCheadleCheadleCheadleCheadleCheadleCheadleCheadleHulmeHulmeHulmeHulmeHulmeHulmeHulmeHulmeHulme

AdswoodAdswoodAdswoodAdswoodAdswoodAdswoodAdswoodAdswoodAdswood

EdgeleyEdgeleyEdgeleyEdgeleyEdgeleyEdgeleyEdgeleyEdgeleyEdgeleyShawShawShawShawShawShawShawShawShawHeathHeathHeathHeathHeathHeathHeathHeathHeath

NorthNorthNorthNorthNorthNorthNorthNorthNorthReddishReddishReddishReddishReddishReddishReddishReddishReddish

HeatonHeatonHeatonHeatonHeatonHeatonHeatonHeatonHeatonChapelChapelChapelChapelChapelChapelChapelChapelChapel

HeatonHeatonHeatonHeatonHeatonHeatonHeatonHeatonHeatonNorrisNorrisNorrisNorrisNorrisNorrisNorrisNorrisNorris

ReddishReddishReddishReddishReddishReddishReddishReddishReddish

SouthSouthSouthSouthSouthSouthSouthSouthSouthReddishReddishReddishReddishReddishReddishReddishReddishReddish

BramhallBramhallBramhallBramhallBramhallBramhallBramhallBramhallBramhall

WoodfordWoodfordWoodfordWoodfordWoodfordWoodfordWoodfordWoodfordWoodford

HeavileyHeavileyHeavileyHeavileyHeavileyHeavileyHeavileyHeavileyHeaviley

Mile EndMile EndMile EndMile EndMile EndMile EndMile EndMile EndMile EndCaleCaleCaleCaleCaleCaleCaleCaleCaleGreenGreenGreenGreenGreenGreenGreenGreenGreen

BramhallBramhallBramhallBramhallBramhallBramhallBramhallBramhallBramhallGreenGreenGreenGreenGreenGreenGreenGreenGreen

DavenportDavenportDavenportDavenportDavenportDavenportDavenportDavenportDavenport

WoodsmoorWoodsmoorWoodsmoorWoodsmoorWoodsmoorWoodsmoorWoodsmoorWoodsmoorWoodsmoor

LancashireLancashireLancashireLancashireLancashireLancashireLancashireLancashireLancashireHillHillHillHillHillHillHillHillHill

BrinningtonBrinningtonBrinningtonBrinningtonBrinningtonBrinningtonBrinningtonBrinningtonBrinningtonWoodleyWoodleyWoodleyWoodleyWoodleyWoodleyWoodleyWoodleyWoodley

BredburyBredburyBredburyBredburyBredburyBredburyBredburyBredburyBredbury

BredburyBredburyBredburyBredburyBredburyBredburyBredburyBredburyBredburyGreenGreenGreenGreenGreenGreenGreenGreenGreenCentreCentreCentreCentreCentreCentreCentreCentreCentre

GreatGreatGreatGreatGreatGreatGreatGreatGreatMoorMoorMoorMoorMoorMoorMoorMoorMoor

OffertonOffertonOffertonOffertonOffertonOffertonOffertonOffertonOfferton

HazelHazelHazelHazelHazelHazelHazelHazelHazelGroveGroveGroveGroveGroveGroveGroveGroveGrove

HighHighHighHighHighHighHighHighHighLaneLaneLaneLaneLaneLaneLaneLaneLane

StrinesStrinesStrinesStrinesStrinesStrinesStrinesStrinesStrines

MarpleMarpleMarpleMarpleMarpleMarpleMarpleMarpleMarpleBridgeBridgeBridgeBridgeBridgeBridgeBridgeBridgeBridge

MellorMellorMellorMellorMellorMellorMellorMellorMellorOffertonOffertonOffertonOffertonOffertonOffertonOffertonOffertonOffertonGreenGreenGreenGreenGreenGreenGreenGreenGreen

MarpleMarpleMarpleMarpleMarpleMarpleMarpleMarpleMarple

HawkHawkHawkHawkHawkHawkHawkHawkHawkGreenGreenGreenGreenGreenGreenGreenGreenGreen

RomileyRomileyRomileyRomileyRomileyRomileyRomileyRomileyRomileyCherryCherryCherryCherryCherryCherryCherryCherryCherryTreeTreeTreeTreeTreeTreeTreeTreeTree

CompstallCompstallCompstallCompstallCompstallCompstallCompstallCompstallCompstall

CoteCoteCoteCoteCoteCoteCoteCoteCoteGreenGreenGreenGreenGreenGreenGreenGreenGreen

Ratio score (where 100 = average)

120 to 235 (48)100 to 120 (54)85 to 100 (42)65 to 85 (46)

Figure 2.5: Index of Multiple Deprivation 2004Comparative Illness and Disability Indicator 2001

This map has been reproduced with the kind permission of Ordnance Survey on behalf of The Controller of Her Majesty's Stationery Office.Crown Copyright. Unauthorised reproduction infringes Crown Copyright and may lead to prosecution or civil proceedings. All Rights Reserved. HA100005991 Stockport PCT 2004

Age and sex standardised morbidity/disability ratio derived from a non-overlappingcount of individuals receiving Disability Living Allowance, Attendance Allowance,Incapacity Benefit, Severe Disablement Allowance, and the disability premium of

Income Support.

2.5. Overall prevalence by numbers of conditionsAlthough the QoF does provide some limited information on the number of people registered on more than one disease register for certain conditions (see section 3.2) there is no data about the overall prevalence of combinations, or co-morbidities, of long-term conditions within Stockport; instead we must revert back to national evidence.

Results from the 2002 British Households Panel Survey showed that while around 40% of the respondents reported having no chronic health condition approximately 15% had 3 or more problems; in other words, over a quarter of people with long-standing conditions lived with more than two problems (see figure 2.6).

Figure 2.6: 2002 British Household Panel Survey - Percentage with chronic conditions

1 or 2 problems44.6%

No problems38.7%

3 or more problems 15.5%

The 2005 General Household Survey also asked those people with chronic conditions to report the number of illnesses they were living with, the results showed that on average people with long term health problems lived with 1.6 conditions, with the average number of conditions experienced rising with age (see figure 2.7).

Figure 2.7: 2005 General Household Survey - Average number of chronic conditions (for those with a chronic condition)

1.3

1.61.7

1.8

0.0

0.2

0.4

0.6

0.8

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16-44 45-64 65-74 75 and overAge group

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2.6. Trends over time in overall prevalenceQuestions regarding limiting long-term illness were first introduced to the Census of Population in 1991, meaning that trend data is not very robust at the local level. In 199112.2% of Stockport’s residents reported having a limiting long-term illness, a rate which increased by over 40% over the following decade to a level of 17.7% by 2001. This increase replicated the trend nationally where rates rose from 13.1% to 18.2%.

The General Household Survey provides a more detailed picture in trends in time nationally in levels of long-term conditions and again results show that there has been an increasing trend in the prevalence of long-standing illness recorded (see figure 2.8); although these figures show the most significant increases occurring between 1972 and 1991.

Figure 2.8: 2005 General Household Survey - trends in long-standing illness

21%

24%

29%30%

31% 31%

35%

33%32% 32%

35%

31% 31%

33%

15%

17% 17%18%

19%

22%

20%19% 19%

21%

18% 18%19%

0%

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40%

1972 1975 1981 1985 1991 1995 1996 1998 2000 2001 2002 2003 2004 2005Year of survey (note that data from 1998 onwards has been weighted)

Per

cen

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rtin

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Longstanding illness Limiting longstanding illness

2.7. Trends over time in life expectancy and healthy life expectancyLife expectancy in Stockport is broadly similar to the national average for 2003/2005 at 76.8 years for men and 81.3 years for women and trends over time have shown a significant increase in the longevity of both genders. In England and Wales in 1943/45, around 47.2% of men and 39.9% of women died before their 65th birthday; 60 years later however only 21.9% and 12.5% of men and women respectively failed to meet their 65th birthday.

Nationally in 1943/45 a man reaching their 65 th birthday could expect to live an additional 12.3 years and a woman 14.6 years. By 2003/05 this had increased to 16.8 years in men and 19.5 years in women and in Stockport the pattern is broadly the same. This means that if a man in Stockport reaches his 65th birthday he can expect to live for a further 16.8 years, an additional 4.5 years from a man aged 65 in 1945. A woman reaching 65 can expect to live an additional 19.9 years an increase of 4.8 years from 60 years ago. Most of the gain in life expectancy has been seen in the under 65-age group but for women there has been a steady increasing trend in life expectancy after the age of 65; in men this was less apparent until 1975. A continued trend of increasing life expectancy in this age group will further contribute to aging population.

The nature and quality of these additional years of life is a key issue and one it is hard to be precise about. There does appear to be emerging scientific evidence of the predicted compression of “morbidity” (Fries 1980, 1990) and “dynamic equilibrium” (Manton et al1982). In

the 1980s and 1990s international data from Australia, Canada, France and Japan showed although chronic conditions increased in prevalence there was a rise in disability-free life expectancy (Robine 2003). In the United Kingdom however evidence is not so clear. Figure 2.8 shows that both life expectancy and health life expectancy at age 65 increased for men and women in England and Wales between 1981 and 2001; but the rise in healthy life expectancy has not kept pace with that of life expectancy and therefore the difference is widening for both men and women and more years are being spent in poor health.

Figure 2.8: Life expectancy (LE) and Health Life expectancy (HLE) 1981-2001 - England & Wales

YearMales at 65 Females at 65

LE HLE LE-HLE LE HLE LE-HLE1981 12.97 9.94 2.80 16.92 11.88 5.041991 14.15 10.84 3.31 17.91 12.97 4.942001 15.94 11.62 4.32 19.03 13.17 5.86Gains

1981-2001 +2.97 +1.68 +1.52 +2.11 +1.29 +0.82

Source: Government Actuary’s Department (GAD) 2005

2.8. Disability ClaimantsData from the Office for National Statistics shows that in August 2006 around 12,600 people in Stockport claimed the disability living allowance and 12,000 people claimed either incapacity benefits or severe disablement allowance (see figure 2.9). The majority of those claiming disability living allowance were aged 60 or over, with over 4,500 residents of Stockport in this age group claiming this benefit. Incapacity benefit and severe disablement allowance demonstrated a different age profile, reflecting the working-age criteria for claimants, over 80% of claimants were aged between 25 and 59 years.

Figure 2.9: Benefits Claimants – August 2006

Disability Living Allowance ClaimantsIncapacity Benefit / Severe Disablement

Allowance ClaimantsStockport England Stockport England

Number % Number % Number % Number %Under 16 1,510 12.0% 246,710 10.8% - - - -16 - 24 730 5.8% 126,100 5.5% 700 5.8% 136,710 6.2%

25 - 49 3,290 26.0% 614,240 26.8% 5,580 46.6%1,040,25

0 47.4%50 - 59 2,430 19.2% 459,240 20.0% 4,120 34.4% 737,110 33.6%60 + 4,670 37.0% 846,440 36.9% 1,570 13.1% 280,520 12.8%

All Ages 12,630 100.0% 2,292,730 100.0% 11,970 100.0%2,194,59

0 100.0%Source: Office for National Statistics

Trends in benefit uptake can be seen in figure 2.10; disability living allowance claims increased by 13% (1,500 people) over the five years since 2002 while, conversely, incapacity benefit and severe disablement allowance claims fell by 3% (250 people).

Figure 2.10: Benefits Claimants - TrendsDisability Living Allowance

ClaimantsIncapacity Benefit / Severe

Disablement Allowance ClaimantsStockport England Stockport England

Aug-06 12,620 229,2900 11,980 219,4660Aug-05 12,380 223,7510 12,050 222,3210Aug-04 12,070 217,3470 12,090 225,8170Aug-03 11,590 209,1820 12,070 225,2730Aug-02 11,160 199,5090 12,230 223,8710

Change 02-06 +13.1% +14.9% -3.3% -0.3%Source: Office for National Statistics

3. Types of Conditions

3.1. Categories and examplesThere are numerous chronic conditions and therefore to focus the following analysis national evidence has been used to identify those with the most significant levels of prevalence. The 2005 General Household Survey showed that the four most commonly reported types of longstanding illness among people aged over 16 years were those of the musculoskeletal system (149 per 1000), those relating to the heart and circulatory system (111 per 1000), respiratory problems (63 per 1000) and conditions affecting the endocrine and metabolic system (52 per 1000), results that were also confirmed by the 2005 Health Survey for England which focused on those aged 65 years and above. In addition NSF for long-term conditions also puts an especial emphasis on neurological conditions and therefore these have also been included in the subsequent analysis.

Therefore this needs assessment focuses on the following five categories:Category Examples

Musculoskeletal: Arthritis, osteoporosis, spinal injuries Circulatory: Chronic heart disease, stroke Respiratory: Asthma, chronic obstructive pulmonary disease (including bronchitis and

emphysema), cystic fibrosis Endocrinology: Diabetes Neurological: Epilepsy, Multiple Sclerosis, Parkinson’s Disease, Alzheimer’s Disease

3.2. QoF DataOne of the best local sources of prevalence information is the QoF (Quality and Outcomes Framework) in which local GP practice report the numbers of people on disease registers for certain conditions. It should be noted that this is not a count of Stockport residents; it is rather a count of people registered with GP practices located in the borough, where ever the patient lives. It is also worth noting that QoF data is of key importance as an indication of the burden of long-term conditions on primary care services; effective commissioning of these GP practice led services will be vital to the success of any strategy developed for long-term conditions.

Figure 3.1 below shows the number of people identified on each of the disease registers under the 5 categories of long-term conditions listed above and the crude prevalence rates in Stockport compared to the national average. The table also includes information about identifiable co-morbidities, other long-term conditions which are not included in the 5 groups and end of life care.The headline from the QoF data is that at least a fifth of the total (all age) population registered at Stockport GPs have at least one long-term condition relating to circulatory disease, respiratory disease or diabetes; in other words over 60,000 people in the borough have at least one long-term condition. Over 2,000 people in the borough (0.8% of the population) are on disease registers for both CHD and diabetes.

The QoF data for specific conditions is discussed in the following sections, structured by the broad categories listed above. The data is presented alongside evidence about the prevalence of other long-term conditions from national studies, the results of which have been applied to the local population to provide a local estimate of the burden of the disease.

Figure 3.1: 2006/07 QoF Disease Registers – Relating to long-term conditions

Disease

Stockport Practices (estimate at 31/03/07)

England

NumberRate per

1,000Rate per

1,000MUSCULOSKELETAL CONDITIONS- - - -CIRCULATORY CONDITITONSCoronary Heart Disease (CHD) 12,661 43.0 35.5Heart Failure 2,837 9.6 7.9Stroke & Transient Ischaemic Attack 5,530 18.8 16.2Hypertension 39,374 133.6 124.7Atrial fibrillation 4,307 14.6 13.0Chronic Kidney Disease (CKD) 5,152 17.5 22.4RESPIRATORY CONDITIONSAsthma 18,855 64.0 57.7Chronic obstructive pulmonary disease (COPD) 4,736 16.1 14.3ENDOCRINE CONDITIONSDiabetes mellitus (aged 17+) 10,377 35.2 36.3Hypothyroidism 7,588 25.7 24.9NEUROLOGICAL CONDITIONSEpilepsy (aged 18+) 1,754 6.0 5.9Dementia 1,441 4.9 4.0Learning Difficulties 714 2.4 2.6OTHER CONDITIONSMental health (schizophrenia, bipolar dis. & other psychoses)

2,103 7.1 7.2

MULTIPLE CONIDTIONS (co-morbidity)Any combination of CHD, stroke, hypertension, diabetes, COPD or asthma

62,107 210.7 195.6

Both CHD and diabetes (i.e. at least 2 diseases) 2,356 8.0 -END OF LIFEPalliative Care 227 0.8 0.9Source: QMAS

3.3. MusculoskeletalUnfortunately the QoF provides no information on musculoskeletal conditions, despite the fact that this group of problems has been identified as the most prevalent nationally. As stated above the 2005 General Household Survey showed that among people aged over 16 years 149 per 1000 reported having a long-term condition relating to the musculoskeletal system, extrapolating this figure to Stockport this would suggest that approximately 34,000 people in the borough live with these type of conditions.Evidence from the Arthritis Research Campaign (www.arc.org.uk) suggests that more than 7 million adults in the United Kingdom (15% of the population) have long-term health problems due to arthritis and related conditions, again in Stockport this would amount to approximately 34,000 people. The organisation also suggests that around 387,000 people in the United Kingdom have rheumatoid arthritis, roughly 0.8% of the adult population; in Stockport this would equate to around 1,800 people

The National Osteoporosis Society (www.nos.org.uk) estimates that there are around 3 million people in the United Kingdom with osteoporosis; extrapolating to Stockport this gives an estimate of approximately 17,000 people locally. The society also suggests that a half of all women and a fifth of all men will suffer a fracture after the age of 50, the overwhelming majority as a result of bone fragility. In Stockport this would mean over 27,000 females and almost 10,000 men suffering fractures later in life.

http://www.nos.org.uk/

‘Two people in a population of 100,000 experience a traumatic spinal injury every year’ (www.longtermconditions.csip.org.uk); in Stockport this statistic estimates that approximately 6 people will suffer from a traumatic spinal injury each year.

3.4. CirculatoryThe 2005 General Household Survey showed that among people aged over 16 years 111 per 1000 reported having a long-term condition relating to the circulatory system, extrapolating this figure to Stockport this would suggest that approximately 25,000 people in the borough live with these type of conditions.

Circulatory conditions are currently covered in depth within the QoF, and crude rates within Stockport are higher than the national average for each of the various conditions, apart from Chronic Kidney Disease. The biggest difference is within Coronary Heart Disease where rates are 20% higher locally than nationally. It is worth noting that, as Stockport has a slightly older age profile than the national average, crude rates are not necessarily a reliable measure, however data does not currently allow us to produce age standardised rates. It’s also worth noting that for the last fifteen years Stockport has conducted a comprehensive cardiovascular risk factor screening programme for patients aged over 35 years, this may have led to higher rates of identification in the PCT.

The QoF suggests that at Stockport GP practices there are currently 39,400 people identified as hypertensive, 12,700 people on a disease register for coronary heart disease and 5,500 on a disease register for stroke.

3.5. Respiratory ConditionsThe 2005 General Household Survey showed that among people aged over 16 years 63 per 1000 reported having a long-term condition relating to the respiratory system, extrapolating this figure to Stockport this would suggest that approximately 14,000 people in the borough live with these type of conditions.

The QoF data covers the two most prevalent long-term respiratory conditions, namely asthma and COPD, for both these conditions the local crude prevalence reported is higher than the average for England. Although again it is worth noting that, as Stockport has a slightly older age profile than the national average, crude rates are not necessarily a reliable measure. Over 18,800 people in the area have been diagnosed as asthmatic and 4,700 people have been placed on a disease register for chronic obstructive pulmonary disease (COPD).

The other major respiratory condition not included in the QoF is cystic fibrosis, which affects over 7,500 people in the United Kingdom (www.cftrust.org.uk); extrapolating to Stockport this gives an estimate of approximately 350 patients within the area.

3.6. EndocrineThe 2005 General Household Survey showed that among people aged over 16 years 52 per 1000 reported having a long-term condition relating to the endocrine and metabolic system, extrapolating this figure to Stockport this would suggest that approximately 12,000 people in the borough live with these type of conditions.

The QoF data again covers the two most prevalent long-term endocrine conditions, namely diabetes and hypothyroidism, for both these conditions the local crude prevalence reported is broadly similar across England. Although again it is worth noting that, as Stockport has a slightly older age profile than the national average, crude rates are not necessarily a reliable measure.

http://www.longtermconditions.csip.org.uk/

Over 10,400 people aged 17 and over in the area have been diagnosed as diabetic and 7,600 people have been placed on a disease register for hyperthyroidism.

3.7. NeurologicalThe particular focus of the NSF for long-term conditions is on neurological conditions, and according to the national documentation taken together, neurological conditions are common with approximately 10 million people across the United Kingdom having a neurological condition; over 8 million of these people are affected but are able to manage their lives on a day to day basis while 350,000 of these people require help for most of their daily activities. In Stockport these estimates would suggest that around 47,000 people in the borough have a neurological condition, 37,000 of whom will be able to cope day to day, but 10,000 people who will need more support. At the extreme there are likely to be around 1,600 people who need help with most of their daily activities.

Local evidence from QoF shows that although crude rates of learning disability and epilepsy are broadly similar to the national average; rates of dementia in Stockport however are more than a fifth higher. Currently there are around 700 people on the learning disability register, 1,400 people on the dementia register and 1,800 people aged 18 and over on the epilepsy register. It’s worth noting that although the QoF estimates that 1,400 people in the borough have dementia national evidence would suggest that 2,800 people will have Alzheimer’s disease.

Nationally, the most prevalent neurological conditions are those classified as headaches, and using evidence gathered in the Neurological Alliance publication ‘Neuro Numbers’ we can estimate that around 42,000 people in Stockport are likely to suffer from migraines, 8,500 of whom will do so chronically. Approximately 5,600 people in the borough will have chronic tension headaches and around 280 people are likely to suffer cluster headaches.

Evidence from the NSF and Neuro Numbers states that ‘around 17 people in a population of 100,000 are likely to develop Parkinson’s disease each year; if this data is extrapolated to Stockport this means around 50 people in the borough are likely to develop Parkinson’s disease every 12 months. The total prevalence of Parkinson’s disease is estimated to be 200 per 100,000; giving an estimate of approximately 560 people with the condition in Stockport.

Again according to the document Neuro Numbers there are approximately 110,000 people in the United Kingdom suffering from Cerebral Palsy and if this data is extrapolated to Stockport this means around 500 people in the borough are likely to have this condition. Similarly Neuro Numbers states that there are approximately 85,000 people in the United Kingdom suffering from Multiple Sclerosis and if this data is extrapolated to Stockport this means around 400 people in the borough are likely to have this condition at any one time.

Evidence from the same source also suggests that between 850 and 1,400 people in Stockport will have ME, while 650 people will be suffering the long term effects of a brain injury. Other neurological conditions which are likely to be prevalent include ataxia, including Friedrich’s ataxia, where estimates suggest that around 14,100 people in the borough will have this condition, and essential tremor which around 2,400 people in the area are likely to have.

Other neurological conditions with lower estimates of prevalence are also included in the document, a summary of their estimated burden in Stockport are listed in Figure 3.2.

Figure 3.2: Estimates of Stockport prevalence of less common neurological conditions (from Neuro Numbers)

Condition Estimated Number in StockportAtaxia-Telangiectasia 1Charcot-Marie-Tooth Disease 113Dystonia (primary idiopathic) 183Huntington’s disease 38Motor neurone disease 20Multiple system atrophy 3Muscular dystrophy 141Myasthenia gravis 84Narcolepsy 141Neurofibromatosis 113Post-polio syndrome 282Progressive supranuclear palsy 17Rett syndrome <1Spina Bifida and Hydrocephalus 68Tourette syndrome 113Tuberous sclerosis 39Source: Neurological Alliance & Stockport PCT

3.8. Other ConditionsThis section focuses in turn on two other categories of long-term condition not described above but for which either there is local data or a local interest for including them in any strategy developed. These categories are long-term mental health disorders and sensory impairment.

3.8.1. Mental HealthThe QoF data again includes a disease register relating to severe long-term mental health conditions including schizophrenia, bipolar disorder and other psychoses. Around 2,000 people registered with Stockport GP practices have been diagnosed with one of these conditions, a crude rate of 7.1 per 1,000; similar to the national average.

3.8.2. Sensory impairmentAccording to the NHS Information Centre 555 people were registered as blind and 880 as partially sighted in Stockport in 2006, the vast majority of whom (76%) were aged over 75 years. Of those who were registered blind 375 had an additional disability; the most common co-morbidities being hard of hearing (120 people) and physical disabilities (235 people).

There is no local source of information regarding the number of deaf people in Stockport but national evidence (www.rnid.org.uk) suggests that there are 8,945,000 deaf and hard of hearing adults and 20,000 deaf children aged 0 – 15 years in the United Kingdom; extrapolating to Stockport this give estimates of 41,800 adults and 100 children. Of the estimated 9 million deaf and hard of hearing adults nationally 688,000 are expected to have a severe or profound deafness; which equates to 3,200 people locally, and 6,471,000 are expected to be aged 60+; which equates to around 32,000 people locally.

http://www.rnid.org.uk/

3.9. CarersCurrently there are 227 patients identified through QoF as being in receipt of palliative care, a crude rate of 0.8 per 100,000 slightly below the national average.

The 2001 Census showed that in Stockport more than 30,000 people, over 10% of the population, provide unpaid care to relatives, friends or neighbours because of long-term illness, disability or the problems of old-age. Of these people the majority (21,500 or 72%) give care for between 1 and 20 hours per week, but over 5,500 (19%) give care for more than 50 hours a week.

The majority of care givers are adults of working age, with 78% aged between 20 and 64 years. However there are 1,000 care givers aged under 20 years, the majority giving between 1 and 19 hours care a week, and there are 2,000 care givers aged 75 years and above, over 40% of whom provide more than 50 hours of care a week. The amount of care given in time, increases as carers age.

Overall 88% of carers describe themselves as being in good or fairly good health; however of those providing 50 or more hours of care a week, almost 20% describe their health as not good.

4. Impact on services

4.1. National EvidenceNationally the Department for Health have estimated that of the eleven leading causes of hospital bed use in the United Kingdom, eight were due to conditions which if community care were strengthened could lead to a fall in admissions. 50% of bed day use is accounted for by only 2.7% of all medical conditions, most of which are chronic diseases.

They also cite evidence from the British Household Panel Survey which showed that having a chronic disease meant that people were far more likely to need health and social care. Patients with a chronic disease accounted for 80% of all GP consultations, were twice as likely to be admitted to hospital and once admitted they stayed in hospital disproportionately longer; this use of health services rose exponentially for people with more than one longstanding problem. In addition the Neurological Alliance found that neurological conditions accounted for 20% of acute hospital admissions and were the third-most common reason for seeing a GP.

4.2. Local Admissions to HospitalFigure 4.1 shows inpatient admissions for local residents for the key long-term conditions outlined in section 3 (using the primary diagnosis of the admission episode to categorise the admissions). As a whole these conditions account for almost 10% of all admissions, resulting in around 7,200 hospital stays in 2005/06. It’s worth noting that many of the admissions not identified in figure 4.1 may be acute episodes linked to a chronic condition, especially those relating to digestive diseases and ‘symptoms, signs and ill defined conditions’, which together account for almost a quarter of all admissions.

Conditions relating to circulatory disease, respiratory illness and mental health disorders are the ones most likely to result in a hospital admission, with these three groups accounting for approximately three quarters (73%) of the identified ‘long-term condition’ admissions. These three groups also account for significant proportions of the total number of admissions in their respective disease categories, 58% of all admissions due to circulatory problems in the year have been linked to long-term problems, 25% of all respiratory admissions have been identified

and almost 80% of all admissions due to mental or behavioural problems have been selected (with only those due to substance misuse excluded).

The characteristics of Stockport residents admitted for the conditions listed in figure 4.1 were different to the characteristics of those Stockport residents admitted for any condition over the year. Unsurprisingly, given the pattern described in section 2.2, people admitted for chronic conditions tend to be much older than the general profile, with the average age for those admitted for reasons relating to long-term conditions being 59 years compared to only 49 years for all those admitted, i.e. a difference of almost 10 years. 49.6% of admissions for the conditions outlined in figure 4.1 were for people aged 65 years and above and 28.7% of these admissions were for those aged 75 years and over; the averages for all admission for these age groups were 32.4% and 18.6% respectively.

Admissions for long-term conditions were also much more likely to be unplanned, in 2005/06 66.8% of admissions for these conditions were an emergency admission compared to only 41.6% of all admissions over the same period. In terms of the care received once patients were admitted to hospital, 72.4% of admissions for long-term conditions had no procedure associated with them, compared to only 49.3% generally. 76.4% of patients admitted for a long-term condition who had a primary operation were a planned admission, whereas 85.9% of those patients admitted for a long-term condition who did not have a primary operation were an emergency admission.

Once patients were admitted to hospital as a result of a long-term condition they were also much more likely to have a longer length of stay when contrasted with all those admitted over the year. Data shows that for those admitted for conditions listed in figure 4.1 only 34.9% of patients were discharged in under two days, compared to 64.0% of patients admitted for any reason. In 2005/06 15.0% of all individuals admitted for conditions listed in figure 4.1 had a length of stay in excess of 28 days compared to only 3.4% of all admissions. The average length of stay (for those with a length of stay under 1 year) was 16.7 days for those admitted for a long-term condition compared to an average of 4.7 days generally.

Figure 4.1: 2005/06 Inpatient Admissions – for key long-term conditionsAdmissions

Musculoskeletal

Arthritis 365Osteoporosis 44Spinal injuries (fracture, dislocation or nerve damage) 85TOTAL 494

Circulatory

Chronic heart disease 634Acute heart disease 546Hypertension 45Angina 666Heart failure 394Stroke (including acute episodes) 517Chronic kidney disease 263TOTAL 2,802

Respiratory

Asthma 390COPD (inc. bronchitis & emphysema) 623Cystic fibrosis 62TOTAL 1,075

EndocrinologyDiabetes 521Hypothyroidism 8TOTAL 529

Neurological

Epilepsy 265Multiple Sclerosis 59Parkinson’s Disease 20Alzheimer’s Disease 52Migraine & headache 73Cerebral palsy 14CFS / ME 2Ataxia 6Charcot-Marie-Tooth Disease 0Dystonia (primary idiopathic) 8Huntington’s disease 0Motor neurone disease 11Multiple system atrophy 0Muscular dystrophy 5Myasthenia gravis 4Narcolepsy 0Neurofibromatosis 0Post-polio syndrome 0Progressive supranuclear palsy 0Rett syndrome 0Spina Bifida & Hydrocephalus 0Tourette syndrome 0Tuberous sclerosis 0TOTAL 519

Other

Organic, inc. symptomatic, mental disorders 177Schizophrenia, schizotypal & delusional disorders 410Mood [affective] disorders 610Neurotic, stress-related & somatoform disorders 120Behavioural syndromes ass. with physiological disturbs / physical fact’s 15Disorders of adult personality & behaviour 80Mental retardation 3Disorders of psychological development 7Behavioural & emotional disorders- onset usually in childhood & adolesen. 2Visual disturbances & blindness 27Hearing loss 50TOTAL 1,501

TOTAL Source: CMS 7,183

Of those admitted for a long-term condition in 2005/06, those admitted as an emergency were much more likely to have a longer length of stay as compared to those planned admissions, 68.5% of patients with a planned were discharged within 48 hours compared to only 23.9% of emergency admissions. Similarly 62.7% of those with a primary operation were discharged within 2 days compared to only 24.4% of those with no associated procedure.

Specific analysis for admissions relating to COPD, undertaken to inform the development of specialist services, has shown that of those people admitted in 2005/06 for long-term respiratory problems, almost a third had also had an admission for the same reason in 2004/05.

Local data on managing very high intensity users (VHIU) for delivering active case management (ACM) shows that high intensity and very high intensity service users have on average 3 or more long-term conditions. Using the King Fund ‘patients at risk of readmission’ (PARR) protocol it has been estimated that around 1,400 people in Stockport are at a greater than 50% risk of being admitted to hospital in the 12 months, the vast majority of whom are elderly and living with a long term health issue. Data relating to ‘ambulatory care sensitive conditions’ shows that in 2005/06 around 2,800 patients were admitted as a result of a chronic (i.e. long-term) complaint that perhaps should have been managed in the primary or community settings; the majority of these admissions (80%) were an emergency, rather than planned, episode of care (see figure 4.2).

Figure 4.2: 2005/06 Inpatient Admissions - Patients Registered at Stockport GP Practices - Ambulatory Care Sensitive Conditions

AdmissionsAll

AdmissionsPlanned Admissions

Emergency Admissions

Other Admissions

Acute

Cellulitis 13 385 5 403Convulsions & epilepsy 26 507 5 538Dehydration & gastroenteritis 202 301 2 505Dental conditions 704 54 3 761Ear, nose & throat infections 126 606 11 743Gangrene 11 45 5 61Pelvic inflammatory disease 52 27 79Perforated / bleeding ulcer 2 44 3 49Pyelonephritis 1 68 69Ruptured appendix 25 25

Acute Total 1137 2062 34 3233

Chronic

Angina 66 593 15 674Asthma 11 375 3 389COPD 16 645 2 663Congestive heart failure 18 386 8 412Diabetes complications 310 106 5 421Hypertension 6 24 30Iron deficiency anaemia 103 75 1 179Nutritional deficiencies

Chronic Total 530 2204 34 2768

VaccineInfluenza & pneumonia 21 539 17 577Other vaccine preventable 153 13 2 168

Vaccine Total 174 552 19 745TOTAL 1841 4818 87 6746Source: CMS

KEY FINDINGS

If extrapolated to Stockport national figures suggest that around 82,000 people in the borough have a chronic health problem.

The 2001 Census of Population showed that 17.7% of the resident population of Stockport (50,300 people) described themselves as having a long-term illness which limited their day-to-day activities.

The prevalence of limiting long-term illness within Stockport increased sharply with age with over 75% of those aged 85 years and above reporting having such a condition. This is particularly significant as older people are making up an increasing proportion of our population.

It is worth noting, however, that of the 50,300 people with a limiting long-term illness only 4,200 were aged over 85 years due to the low population size at this age. The majority of people with limiting long term illnesses were aged between 60 and 79 years, around 20,000 people or 40% of the total.

Around 3,000 children and young people aged under 20 years and 2,000 people in their 20s in Stockport were identified as living with a limiting long-term illness

Geographical evidence suggests that rates of limiting long-term illness increase as deprivation levels rise, despite the fact that deprived areas tend to have younger populations. Evidence from the 2001 Census suggests that the five most deprived wards in the borough contain a quarter of those with limiting long-term illnesses, despite having a total population share closer to 20%.

The 2004 Index of Multiple Deprivation’s ‘comparative illness and disability indicator’ (which used age and sex standardised data relating to the uptake of various types of financial benefits for those living with long-term illness and disability) showed a distribution that followed patterns of known deprivation. The ‘priority 1’ areas of Brinnington, Lancashire Hill and Adswood and Bridgehall were all identified as having levels of uptake more than 25% above the England average.

The 2005 General Household Survey showed that on average people with long-term health problems lived with 1.6 conditions, with the average number of conditions experienced rising with age. The 2002 British Households Panel Survey showed that over a quarter of people with long-standing conditions lived with more than two problems.

The General Household Survey results showed that nationally there has been an increasing trend in the prevalence of long-standing illness recorded with the most significant increases occurring between 1972 and 1991.

Life expectancy in Stockport is broadly similar to the national average in 2003/2005 at 76.8 years for men and 81.3 years for women, trends over time have shown a significant increase in the longevity of both genders. The nature and quality of these additional years of life is a key issue as initial national evidence suggests that the difference between overall life expectancy and health life expectancy is widening for both men and women and therefore more years are being spent in poor health.

Trends in benefit uptake show that disability living allowance claims increased by 13% over the five years since 2002 to a level of 12,620 while, conversely, incapacity benefit and severe disablement allowance claims fell by 3% to 11,980.

QoF data shows that at least a fifth of the total (all age) population registered at Stockport GP practices have at least one long-term condition relating to circulatory disease, respiratory

disease or diabetes; in other words over 60,000 people in the borough have at least one long-term condition. Over 2,000 people in the borough (0.8% of the population) are on disease registers for both CHD and diabetes.

The British Household Panel Survey showed that having a chronic disease meant that people were far more likely to need health and social care. Patients with a chronic disease accounted for 80% of all GP consultations, were twice as likely to be admitted to hospital and once admitted they stayed in hospital disproportionately longer; this use of health services rose exponentially for people with more than one longstanding problem.

Local data suggests that the key long-term health conditions account for almost 10% of all admissions, resulting in around 7,200 hospital stays in 2005/06.

Local data on managing very high intensity users (VHIU) for delivering active case management (ACM) shows that high intensity and very high intensity service users have on average 3 or more long-term conditions. Using the King Fund ‘patients at risk of readmission’ (PARR) protocol it has been estimated that around 1,400 people in Stockport are at a greater than 50% risk of being admitted to hospital in the 12 months, the vast majority of whom are elderly and living with a long term health issue.

Data relating to ‘ambulatory care sensitive conditions’ shows that in 2005/06 around 2,800 patients were admitted as a result of a chronic (i.e. long-term) complaint that perhaps should have been managed in the primary or community settings; the majority of these admissions (80%) were an emergency, rather than planned, episode of care.

The 2001 Census showed that in Stockport more than 30,000 people, over 10% of the population, provide unpaid care to relatives, friends or neighbours because of long-term illness, disability or the problems of old-age. Of these people the majority (21,500 or 72%) give care for between 1 and 20 hours per week, but over 5,500 (19%) give care for more than 50 hours a week. The amount of care given in time, increases as carers age.

Long Term Conditions - RR

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