Long-term Conditions

The proactive management of people with long-term conditions, including the promotion of self-care by patients, is a key priority for the NHS.  General practice has a central role in delivering more integrated and personalised care, and in implementing policies that target ‘at-risk’ individuals with appropriate interventions.

The Kings Fund

Long-term conditions (LTCs) are many and varied, encompassing areas such as asthma, diabetes, skin conditions, cancer, high blood pressure, heart disease, arthritis, ME, chronic pain, Alzheimer’s, stroke, and others. Over time the demography of our population has changed. People are living longer and the lifestyle choices that we make have altered considerably, both of which can adversely impact on our susceptibility to developing a LTC. Public Health England’s National General Practice Profiles have been designed to support GPs, NHS Clinical Commissioning Groups (CCGs) as well as Local Authorities to ensure that they are providing and commissioning effective and appropriate healthcare services for the local population. The tool highlights the outcomes of the Quality and Outcomes Framework (QOF) – a part of the General Medical Services Contract demonstrating GP practice achievement over a number of clinical and public health domains – as well as disease prevalence estimates, hospital admission rates and patient satisfaction. The information can be explored by NHS Southern Derbyshire CCG area, and the GP practices that comprise this group.

NHS Health Checks

The NHS Health Check programme aims to prevent the onset of chronic disease in later life. Everyone between the ages of 40 and 74 who has not already been diagnosed with heart disease, stroke, diabetes or kidney disease should be invited once every five years to have a check to assess their risk of developing these conditions. The NHS Health Check programme was rolled out in Derby in 2009. More recently, a community-based model delivered by the Livewell service has been implemented to increase our uptake across the city by targeting hard to reach groups and providing an NHS Health Check service for patients from GP Practices who do not deliver the programme.

The latest national NHS health check profile for Derby shows that the local proportion of health check invitations and take-up of health checks is significantly lower than the national average. However, it is important to note that there are data quality issues with the offer figures for some local authorities showing a proportion greater than 100%. Between quarter 1 of 2013/14 and quarter 4 of 2015/16, 46.2% of eligible people were invited for a health check. Within this period, 47.8% of invited people received a health check. The latest available data indicates that cumulatively, the percentage of eligible people who have received a health check since 1st April 2013 is 22.1%. This is significantly lower than the national average of 27.4%.

There are a number of factors that could account for this. Nationally, data quality issues with identifying eligible patients and the coding of invites and checks may have skewed the comparability of the data. Derby City uses a sophisticated IT software solution that identifies accurately the number of eligible patients in the population and excludes all the checks that have been done on people who are not eligible. In other areas estimations of such eligibility can reflect a more positive picture.

In addition to data quality and the comparability across the country, five of Derby’s GP Practices have chosen to opt out of the programme since April 2014 which has affected the overall numbers being delivered locally. To help offset the effects of this, a new community delivery model has been specifically working to increase uptake within the five practice populations for whom health checks are not formally delivered. Delivered by Livewell, this community engagement takes place in mosques, work places, libraries and many other community locations to increase accessibility of the service. In 2015/16, 670 NHS Health Checks were completed in the community, of which 338 people (50%) were referred back to their GP for further investigation and/or treatment.

Risk factors

Derby performs comparably with the national average across related risk factors in adults such as obesity, physical inactivity and smoking. However, the percentage of people living in deprivation and hospital admission episodes for alcohol-related conditions are significantly higher than the national and regional averages.

Disease and death

In Derby, 1.6% of patients recorded on practice disease registers have a stroke or transient ischaemic attack (TIA). This is significantly lower than the national and regional average. Derby performs significantly worse than the national average in relation to the following:

• Percentage of patients aged 17 years and over with diabetes prevalence – 7.1%
• Percentage of patients aged 18 years and over with chronic kidney disease (CKD) – 4.3%
• Age-standardised rate of mortality considered preventable from all cardiovascular diseases in people under 75 – 57.3 per 100,000

Derby performs comparably with the national average in relation to the following:

• Percentage of patients with coronary heart disease – 3.2%
• Age-standardised rate of mortality considered preventable from all cancers in people under 75 – 88.8 per 100,000

For more information about the national programme please visit the NHS Choices website where you can also complete a few questions to check your heart age.