Our starting point is good, not least because of the strength of our primary care

Chris Ham, Director of Strategy Unit, Department of Health

Internationally, effective  Management of Long Term Conditions  is linked to new models and innovation in primary care

Most quality indicators are single disease focussed. We need to measure care co-ordination.

People manage their condition as part of their daily lives…they manage it after they have left the clinic….Life is a chronic disease

Rafael Bengoa, Director for Management of Chronic Diseases, World Health Organisation, Geneva

Gerard Anderson, National Programme Director,John Hopkins University, Bloomberg School of Public Health - USA.

Harry Cayton, Director of Public and Patient Involvement, Department of Health

Evercare Programme: Chronic Disease Management and Redesign of Primary and Community Services

Alistair Howie, Chief Executive, Walsall PCT

We need to understand the data we already have

Bringing America to the Eastern Bloc

Sophia Christie, Chief Executive, Eastern Birmingham PCT

In Spring 2003, a clinical team drawn from the diverse health economy east of the A34 visited Kaiser Permanente in California. They were struck by the cultural differences between KP and the NHS and the impact this had on clinical engagement, health outcomes and patient experience.

Team Health: A Vision for Chronic Disease Management in Haringey

Gerry Taylor, Deputy Director of Health Improvement, Haringey PCT

This presentation will outline the vision for managing long term conditions in Haringey and describe one of the initiatives in the strategy. The strategy incorporates a tiered approach moving from those who can best manage their own care with their GP to those who have the most difficulty in managing their own health.

A key part of this strategy is a partnership project where Haringey TPCT are working with DoH and Pfizer Health Solutions to assess the feasibility and impact of an additional service for those people at the top tier. Working with the two local trusts, North Middlesex and Whittington we will identify 600 people with CHD, heart failure and diabetes who meet an agreed set of eligibility criteria. Using a telephone-based approach, four care managers will work with these patients to try to improve their self-management of their condition. Care managers will be supported by an established decision support software programme that has been developed to incorporate national and local guidelines. They will focus on improving patient involvement and motivation in their health through personalised coaching and information.

The programme is based on similar well-evaluated projects in the USA, but this is the first time this specific project will be implemented in the UK. We are therefore carrying out a thorough evaluation of this project and we will highlight some of the issues related to this evaluation. We are just beginning to recruit patients to this project and will describe the steps we have taken to get to this stage and when we expect to be able to share the results of this project.

Around 80% of all care episodes are estimated to constitute ‘self care’. The session presents an overview of the DH strategy to support and facilitate self care. There will be a chance to hear about and discuss the evidence, the potential benefits and the options available to encourage more self care both within Management of Long Term Conditions and the wider context.

Tools For Redesign

Penny Shuttleworth, Workforce Designer,

How the changing workforce programme developed and used the tools for role redesign to impact on improving services for older people by implementing support worker roles across health and social care; and developing the roles of technicians to support annual reviews in primary care.

Self-Management By Organisational Change - Whole System Approach

Bev Bookless, Programme Director, National Diabetes Support Team,NHS Modernisation Agency

At the core of management of long term conditions is the capacity of patients and carers to optimise treatment and self manage. However the Health Service culture and organisation have largely developed its expertise to manage acute episodes. The diabetes NSF have recognised these issues by targeting organisational dimensions. The NDST have specifically set itself organisational objectives which will impact upon self-management. This workshop explores the what, why and how of such work and will generate alternative methods from workshop participants.

The Right Care In The Right Place At The Right Time' - Lessons From A Dermatology Service

Paul Norris, Consultant Dermatologist & Clinical Director of Specialist Medicine, Addenbrokes Hospital; Jenny Brown, Assistant Director of Service Capacity & Development, South Cambridgeshire PCT

The South Cambridgeshire experience of an Integrated Dermatology Care, including an insight into maximising the use of:

• Workforce skills both in primary and secondary care
• Cross-boundary working
• Keeping patients away from hospital, ensuring consultations 'add value'
• Maintaining patient focus and support.

The purpose of this workshop is to look at a technique Kings College Hospital have been using in

Pursuing Perfection.

The technique is called segmentation, not to be confused with segmentation as determined in work on Flow.

To date Kings College Hospital have been using this technique to achieve:

• Differentiation of different patients with different needs and wants
• A first step to individualised care
• Increased scope for self-management
• More targeted use of resources towards those with greater need.

This workshop will run through the technique and use some local examples to show how Kings College Hospital have applied it to date in COPD, Falls and Case Management of Older People's conditions.