Chronic conditions in Wales

A higher proportion of people in Wales have at least one chronic condition (long-term condition) compared with any other UK country

The most commonly reported chronic conditions in Wales are arthritis (14%), respiratory conditions (13%) and chronic heart conditions (9%). Much of the work to address this has centred on a chronic conditions model and framework Designed to improve health and the management of chronic conditions in Wales: An integrated model and framework (2007)

Designed to improve health and the management of chronic conditions in Wales: An integrated model and framework 2007

The framework uses a social model of health and gives a high priority to the social, psychological and emotional consequences of being diagnosed with a chronic condition (p7).
The aim of the framework is to coordinate existing programmes, such as National Service Frameworks, Expert Patient Programmes, Unified Assessment and  care pathways (p10).
The document presents the Welsh Chronic Conditions Model, which has as its key elements:

• broad managed care programmes
• targeting 'high risk' people
• sharing skills and knowledge
• patient and carer involvement in decision making
• self management education
• self monitoring, telemedicine and telecare

The model is illustrated in the diagram below, taken from ‘Designed to Improve Health and the Management of Chronic Conditions in Wales’ 2007 p19).

COT has given broad support for the Framework. Occupational therapists will need to be aware of the recommendations to work across traditional organisational and professional boundaries and to deliver innovative practice which results in better outcomes for clients. (p29)
The framework can be downloaded from the NHS Wales website.

Designed to improve health and the management of chronic conditions in Wales Service Improvement Plan 2008-11

This document takes the aspirations of the Chronic Conditions Management (CCM) model and framework forward into specific actions and targets. Aims, mechanisms/strategies and actions are identified on pp. 5-6 of the document. The aim is to address the needs of people in a comprehensive, well planned way, to reduce variation in service provision and outcomes, and to use resources efficiently. Key mechanisms include:

• health promotion
• prevention and early intervention
• services planned around a generic Chronic Condition Management Care Pathway
• multidisciplinary teams delivering seamless services
• community based health and social care and support
• performance monitoring

 
The document identifies the role of CCM community teams, which are being set up as part of the drive to shift resources from secondary to primary and community teams.  Each team will provide care for a population of between 30,000 and 50,000 people (p17). The functions of these teams are given on p17 of the document.  Important functions for occupational therapists include:

• 'holistic assessment of patient and carers needs including home environmental assessment to identify risks and scope to safeguard independence using adaptations and equipment
• CCM care co-ordinators providing essential overall management
• common pathway offering a range of opportunities to achieve optimum independence
• specialist clinical and professional support
• community support and signposting'

(Source: Designed to improve health and the management of chronic conditions in Wales Service Improvement Plan 2008-11 p17)
 
The document then sets out a ‘maturity matrix’ in order to facilitate improvement in CCM (p26-40).  Elements of this which will be of particular relevance for occupational therapists are ‘independence and self care’, 'care pathways’, ‘professional and skills development’, 'clinical leadership' and ‘clinical networks’. 
 
CCM Local Action Plans have been developed by Local Health Boards and their partners (2008) which are based on analysis of local health needs and services.  Additionally, Local Health Boards are required to include CCM Action Plans within their Health, Social Care and Wellbeing strategies, which run from 2008 to 2011. Three National CCM Demonstrator sites have been established to support implementation of the model. These are based in North Wales, Carmarthernshire and Cardiff. The document can be found here. 
 

Other useful documents

• Designed for Life: Creating World Class Health and Social Care for Wales in the 21st Century (2005)
  A 10 year strategy to improve health and social care in Wales. A key aim is to bring about a shift in resources from secondary to primary and community care.
• A Profile of Long Term and Chronic Conditions in Wales (2006)
• Health Social Care and Wellbeing Strategies produced by each Health Board. All include CCM as a key component
• National service frameworks
  These have been produced for various conditions, such as coronary heart disease, diabetes and renal disease.  The aim of these is to improve basic standards as well as quality of services. There are also four directives:
  1. Service Development Directive for Epilepsy Designed to Tackle Renal Disease in Wales
  2. Service Development and Commissioning Directives: Chronic Non-Malignant Pain
  3. Service Development and Commissioning Directives: Chronic Respiratory Conditions
  4. Service Development and Commissioning Directives: arthritis and chronic musculo-skeletal conditions
• The Management of Chronic Conditions by NHS Wales A report by the Wales Audit Office. http://www.wao.gov.uk/assets/englishdocuments/chronic_conditions_management_eng.pdf

Useful sources of information

National Leadership and Innovation Agency for Healthcare (NLIAH) produces regular e-bulletins.
It is also responsible for operational aspects of Expert Patient Programmes.