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Long Term Conditions Whole System Demonstrators. Tim Ellis/Claire Whittington Department of Health. CSIP - Outcomes from Telecare and Advanced Assistive Technology. Session Aims. Overall context Background to WSDs Lessons so far Next steps. Secondary Care Waiting Lists

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long term conditions whole system demonstrators

Long Term Conditions Whole System Demonstrators

Tim Ellis/Claire Whittington

Department of Health

CSIP - Outcomes from Telecare and Advanced Assistive Technology

session aims
Session Aims
  • Overall context
  • Background to WSDs
  • Lessons so far
  • Next steps
Secondary Care

Waiting Lists

Increase capacity

Long term conditions

Community focus

Improved Health Outcomes

Commissioner Development

NHS & DH Focus












Stronger voice for individuals & communities

Increased support for self care

Service users and carers have more say – person-centred care planning

Integrated health and social care services

Clinicians driving improvement

Renewed LTC focus

White Paper Commitment Whole System Demonstrators

WSDs will explore the exciting possibilities opened up by truly integrated health and social care working supported by advanced assistive technologies such as telehealth and telecare.

  • The objectives of the demonstrators are to:
  • Improve the care co-ordination of those with complex health and social care needs through use of an integrated health and social care system including joint health and social care teams using shared information to benefit systematic chronic disease management programmes;
  • Place a strong emphasis on patient education and empowerment, so that people are fully informed about their condition and are better able to manage it;
  • Provide health and social care commissioners with the right incentives to deliver better care for those with complex needs;
  • Involve the use of assistive technology (telehealth and telecare) in order to improve the health and well being of the individuals and achieve efficiencies in service delivery.
demonstrator profile
Demonstrator Profile

Ivan Lewis MP

Parliamentary Under-Secretary of State for Care Services

Ann Keen MP

Parliamentary Under Secretary of State for Health Services.

Cross Government Interest, Professional Bodies Interest, OGC reviews

selecting the wsd sites
Selecting the WSD Sites




  • The poorest County in England, with a dispersed rural population
  • Population of >500,000
  • 46% of the population live in settlements of <3,000 people
  • 99.1% White British
  • 10.3% of the population are aged 65+; 7.2% 75+ and 2.6% 85+
  • 21% of the population report a limiting long term illness
  • Combination of rural and urban populations
  • Population of 1.37m (excluding Medway UA). Two areas already piloting telehealth Ashford / Shepway population of 211,100 & Dartford / Gravesham / Swanley population of 210,000
  • 3.5% BME
  • 17.3% of the population are aged 65+; 8.4% 75+ and 2.2% 85+
  • Within the target population, individuals report having an average of 1.6 of the three target conditions of HF, COPD, Diabetes
  • One of the most deprived areas in the UK
  • Population of 270,442 - GP registered population of 300,000
  • Population increasing at a higher rate than the London average
  • 2nd most diverse population in the UK - >68% BME; >140 first languages
  • 8.5% of the population are aged 65+
  • 17.3% of the population have a limiting long term illness
  • Highest death rate from stroke and COPD
  • Highest diabetes rate in the UK
  • 2nd highest CHD rate in London
demonstrator target population
Demonstrator Target Population

We are planning to focus on over 7500 service users across the 3 sites:

  • Individuals with health care needs of any age who are at risk of current or future hospital admission, due to at least one of the following conditions: heart failure, COPD or diabetes.
  • Individuals with social care needs aged 18 and over
  • Individuals with both health and social care needs as defined above.
wsds key elements
WSDs – Key Elements



Integrated health &

social care teams



Service Users/Clients/Patients



Integrated health &

social care information

Partnership working: housing, 3rd & independent sector

wsds what it s not about
WSDs – what it’s not about !

“Thanks to the smarter home, a home help is required only twice a year-

to adjust the clock!”

Reference: Bruno von Niman,GSC#10 @ ETSI, Sophia Antipolis, France Health-, care- and mobile e-services

wsd outcomes proving the business case
WSD OutcomesProving the Business Case

The demonstrators will lead to a better understanding of the level of benefit associated with telehealth and telecare in an integrated health and social care environment.

They will also help fast track future change by addressing the key implementation barriers and providing solutions for the wider NHS and Social Care.

  • We will know to what extent the WSD model of care:
    • promotes individuals long term well-being and independence
    • improves individuals and their carer’s quality of life
    • improves the working lives of staff
    • is more cost effective
    • is more clinically effective
    • provides an evidence base for future care and technology models.
demonstrator evaluation
Demonstrator Evaluation

Coordinator role (Birmingham )



  • Service utilisation
  • Impact on costs
  • Clinical measures and patient reported quality of life
  • Mechanisms of impact on service user outcomes and variations between subgroups
  • Patient, carer and professional experience
  • Organisational context and implementation process

King’s Fund, LSE, UCL, Oxford

Manchester, Oxford, Imperial

learning so far
Learning so far
  • Understand your population
  • Plan in advance and recognise the environment will change over the life of your programme
  • Clearly define the whole integrated pathway requirements – involve all the key stakeholders
  • Ensure you have the right resources
  • Ensure you can measure the benefit in a way that satisfies the needs of your key stakeholders
  • Employ rigorous programme/project management
learning to inform wider implementation
Learning to inform wider implementation

Through :

  • Promoting more user focused care and improving the information available to service users
  • Facilitating introduction of integrated care pathways including telehealth and telecare by providing the business case for their effectiveness
  • Encouraging research into the areas that currently provide a barrier to more widespread implementation through the Assisted Living Innovation Platform
  • Guiding the development of integrated health and social care information sources based on national standards through our work with CfH
  • Scoping the requirements for future procurement solutions for assisted living with PASA
  • Sharing lessons learned by the demonstrator sites through CSIP