With an increasing and aging population the structure of provision of care for people with Long Term Conditions was unsustainable. We were tasked to help redesign the provision of care across a population of 1.6million.With a group comprising of experts and using the best available evidence, we were able to provide a report describing what would work for the population.

 

The model was based around care wrapped around populations of 50,000-100,000 and mapped care provision from primary to tertiary care.

 

We adopted an evidence based framework of Risk profiling to identify patients early, Patient Self management and shared decision making.

 

We highlighted the drivers including strengthening provision of out of hospital care, improving transport networks and a strong It to enable record keeping and communication between different caregivers.

 

Our report was presented to the government and has formed the basis of delivering good quality care to patients with long term conditions nationally.