Long-term conditions: sharing learning between two countries

With the global population rapidly ageing, health providers around the world are working to meet the needs of people with long-term conditions. In Northern Ireland, the South Eastern Health and Social Care Trust is working in partnership with the Basque Health Department, using learning from the Basque Chronic Patients Strategy to produce improvements in quality, equity and cost efficiency.

We asked Charlotte McArdle, the Trust’s Director of Primary Care, Older People and Executive Director of Nursing, and GP and clinical lead Chris Leggett, to share some of their learning.

What are the key features of the Basque strategy?

Chris: It’s about meeting the needs of people with long-term conditions by being proactive, with better integration of primary and secondary care, and stratifying referrals so that you focus resources at those most at risk.

Charlotte: With this approach, a patient with a long-term condition knows who to contact when they start to get a little unwell rather than waiting till they’re in a crisis. There’s a huge emphasis on prevention and on putting the patient at the centre of their care.

Why did the Trust choose to work with the Basque region?

Charlotte: We became aware of the Basque strategy through our mutual links with the Institute of Health Improvement. From a cultural and value base, there were parallels between the Basque region and our area, in terms of demographics, population size, geography, climate and long-term condition profile. But also, the Basque team were familiar with the improvement methodology and improvement science techniques we used. The comprehensive and integrated nature of the strategy was important too, as was its fantastic evaluation methodology, which was essential to secure clinical engagement. It was a total system approach, evident from the top right down to frontline care.

It’s important to look further afield, or you can risk being quite insular. There are differences – for example, in the Basque region palliative care is heavily reliant on family support, which we’ve struggled with here as people have moved away. So you can’t always apply the learning directly, but you can apply the principles. The fact that the learning took place in an international context was almost incidental to the project.

For us, the learning was a total package. I haven’t heard or seen anything so well embedded, owned by staff and demonstrating outcomes, anywhere else.

Which areas of your work have been influenced by this project?

Chris: One example is our screening initiative for patients at risk of developing diabetes. People are referred to an intensive education and health promotion scheme, focusing on diet and activity levels, to prevent Type 2 diabetes.

Another example is an enhanced service where GPs are paid to identify patients over 85 who might be at increased risk of increased hospital admissions, and carry out a home-based assessment. The assessments often detect undiagnosed problems and can highlight wider issues such as loneliness, which can be addressed by linking the person up with voluntary services.

We are also developing a community ward model with an improved network of community nurses, to reduce hospital admissions and ensure earlier discharge. For example, our respiratory consultant screens her waiting list for patients who are likely to benefit from undergoing tests or seeing community teams first, so that she can see those in most urgent need of a consultation. She spends more time filtering referrals, but it has kept her waiting list down and is more flexible and efficient.

Charlotte: It also feeds into our new long-term conditions strategy, which places the individual at the centre of care, with district nurses and GPs as care coordinators, calling in other teams as needed. This is closely aligned to Transforming Your Care – the Northern Ireland strategy for health and social care, which places huge emphasis on managing long-term conditions and managing urgent care.

How is the new approach affecting patients’ lives?

Charlotte: By intervening earlier, we aim to prevent people from becoming seriously ill and improving their quality of life. We have early indications that we’ve been able to reduce hospital admission for people with long-term conditions through our support packages. Eventually, our long-term aim is to reduce the number of people in the area who have long-term conditions. The key for us is supporting people to play a stronger role in making decisions about their care.