http://www.kirklees.nhs.uk/fileadmin/documents/publications/PBC_Business_Plan_Oaklands_2008-2009

3. Provision of appropriate information on healthy living / healthy lifestyles to reduce the risk of developing long term conditions Issues / Difficulties The practice has identified this as a significant priority area and has submitted a business case to the PCT in April 2008. We propose to use underspends from our 06/07 PBC budget to fund a 0.44 full time equivalent GP on a three year pilot basis to provide the practice with enough capacity to identify, screen and treat patient who are either at risk of developing long term conditions or currently have long term conditions where their management could be improved.

Although the JSNA identifies that “The Valleys” area has the lowest rates of premature deaths from the major killers of cancer and heart disease, it also identifies that 20% of adults smoke on a daily and that 10% of adults are obese. The JSNA also identifies that two in three adults were not physically active enough to benefit their health and up to one third of people locally binge drink. The Practice believes that these are significant risk factors for the development of long term conditions e.g. respiratory illness, renal disease, heart disease and liver disease, which in time will become a major health burden and could potentially increase the rate of premature death from cancer and heart disease.

The Practice also believes that this business case has very clear links to the operating framework (Vital Signs) e.g. via the proportion of people with long terms conditions supported to be independent and in control of their condition, the rates of hospital admissions for ambulatory care and sensitive conditions per 100,000 population, less than 75 year old CVD mortality rate amongst many others.

Current Position/Proposal As identified above, the Practice as submitted a business case, which has received approval for funding and the Practice will be in a position to implement this business case from May 2008.

Expected Outcomes / Performance Indicators The business case itself contains a number of expected performance measures, which includes analysis of saved referrals costs, saved prescribing costs, saved hospital admissions and hopefully also reduce length of stay on the back of better management of long term conditions 6.

Mental Health Case Manager Aims • To improve the capacity of the primary care metal health team.

• Provide support to carers and patients with dementia.

• Identify physical and/or mental health deterioration at an early stage to reduce unnecessary hospital admissions.

• Liaise with Social Services to provide holistic assessments and ensure patients and carers receive appropriate benefits.

Issues Although there is no tariff for mental health, the practice would seek to prioritise this scheme from within residual 06/07 underspends or potential 07/08 underspends.

The practice would seek to pilot such a scheme over two to three years and would need to identify £36,000 to £50,000 to fund this scheme. Clearly failure to secure this underspend will jeopardise the scheme!

Expected outcomes • Improved integration of care for patients with dementia.

• Reduced hospital admissions and decreased length of stay.

• Improved medicines management (Compliance and Concordance) with reduced risk of iatrogenic illness and drug wastage.