Integrating care for long-term conditions

There are an estimated 7 million people living with cardiovascular disease (CVD) in the UK. An ageing and growing population and improved survival rates from cardiovascular events could see this number rise still further.

The problemGordon Richardson, 77, from Rhos-on-Sea

CVD is a long-term condition, often linked to co-morbidities such as diabetes, hypertension and obesity.

With people living longer lives it’s expected that the numbers living with multiple long-term conditions will continue to rise, leading to billions of pounds in additional health and social care costs.

The current healthcare system is struggling to cope with the increased demand of managing people with multiple LTCs, who are in and out of the hospital due to the fragmentation of health services.

The call for change

Outcomes are consistently poor for patients who receive sub-optimal care. Specialist services and redesign of care pathways can improve prognosis and quality of life. 

The NHS has recently pledged to develop new models of care, transforming their way of working to support LTC management within primary care.

People with LTCs and co-morbidities can have a better quality of life if:

  1. they have improved access to treatment and care,
  2. it is delivered via an integrated approach,
  3. there is an improved interface between primary, community and acute services.

What we did

We funded a two year programme at nine NHS organisations across the UK to improve service provision for people living with CVD by means of implementing integration across the primary and secondary care interface.

They were concerned to make sure I got the right treatment.

Gordon Richardson, heart failure patient

Another key part of the programme focused on improving the skills and capacity of primary / community care to offer self-management for people living with CVD. 

The nine projects in our Integrated Care pilot adopted the programme to their local context using a variety of approaches.

Some common themes that emerged from the interventions were: 

  • Early Supported Discharge/Hospital in-reach
  • Home visits with specialist services
  • Nurse-led community and hospital clinics
  • Multi-speciality clinics and networking
  • Practice Risk Register auditing & training

You can now download our new CPD accredited Integrated Care summary booklet, which highlights three of the NHS organisations and summarises their approach to integrating care for CVD patients. 

We externally evaluated the programme throughout the entire set up and delivery. The final report by independent evaluators ICF GHK highlights the outcomes and impact produced by each project within the programme. The report also generates a narrative on the overall programme level outcomes and makes recommendations based on the programme of work delivered.

Read our full external evaluation report on the programme.

Evidence for change

Each of our pilot sites reported on a variety of positive outcomes from their local service redesign/education and audit programmes:

  • improved identification, diagnosis and management of CVD patients 
  • improved patient quality of life and patient satisfaction
  • significant increase in patients’ ability and confidence to self-manage and knowledge of their condition
  • up-skilling of HCPs adopting a more holistic approach such as consideration of psychological and social care needs
  • implementation of new care and referral pathways that reflect an integrated service
  • improved links across the local health economy between service providers
  • reduction in unplanned hospital admissions and reported cost savings
  • adoption of care pathways and services for managing other LTCs such as diabetes 

What we found

  1. Integration does not always result in tangible cost savings in a health system due to the shift of resources from secondary to primary care. However, if services are joined up there are likely to be substantial cost savings by prevention of hospital admissions due to better access to care in the community. 
  2. Most of the projects within the programme have had their services fully commissioned and sustained beyond the BHF funding.
  3. Two of the projects reported combined savings of over £1.5 million over 1.5 years, mainly due to hospital admission avoidance. The cost benefit ratio of the service equated to a savings of almost £9 for every £1 spent on healthcare.*

* The savings were based on number of hospital admissions avoided multiplied by cost of bed days (national tariff) per length of admission (based on the National Heart Failure Audit). Treatment costs were also incorporated into the expenditure.

Further reading

For a summary of our Integrated Care project, focusing on three NHS organisations across the UK, you can read our CPD accredited Integrated Care booklet.

For more in-depth detail on the individual projects you can read our external evaluation from independent evaluators ICF GHK.

Read more about the range of our evidence based innovative pilot services.

Interested in setting up your own integrated care service? Our online Business Case Toolkit resource could help you make your case.

For any further information please email [email protected]