TVSCN > Networks > Long Term Conditions

Long Term Conditions

Utilising the “House of Care” & Patient-centred care

Enhancing Quality of Life for People with Long Term Conditions

Long term conditions (LTC’s) impact across all of the clinical networks and majorly supports the focused clinical work of the networks.

Our LTC programme of work is based on the House of Care framework; this approach has, at its heart, patient centred care planning, and recognises that for this to be truly effective, 4 aspects require equal attention;

  1. Patients are engaged and informed- the SCN is undertaking a piece of work reviewing the range and quality of diabetes education programmes across Thames Valley (report due for publication – Sept 15)
  2. Health professional are committed to partnership working- the SCN has commissioned a rolling programme of training in care planning for GP practice’s and integrated care teams.
  3. Organisational and supporting processes- the SCN has secured a range of local experts from across TV and made them available to CCGs to support the adoption of care planning at the local level and to contribute to strategic/ CCG level work on new models of care
  4. Commissioning- the SCN is advising CCGs on the requirements to sustain care planning, and is contributing to discussions on future commissioning opportunities under the co-commissioning agenda. Based on feedback taken from individual LTC Clinical Commissioning Group leads and key others across Thames Valley, the SCN has established a community of interest for the purpose of peer support, sharing and dissemination of ideas, access to nationally recognised examples of good practice for review and local adoption, disseminating national thinking from the National Clinical Director (NCD), and acting as a link between the NCD and local colleagues.

The SCN commissioned a review and syntheses of the evidence on best practice for telehealth for people with long term conditions with specific emphasis on those with multi-morbidities. Commissioning guidance has subsequently been provided to CCGs to inform their consideration of telehealth innovations for inclusion in their two and five year plans.

The SCN is working with Health Education Thames Valley on a joint initiative offering fellowships for community nurses focussing on LTC. Ensuring individual projects had the support of CCGs and aligned to CCG plans and priorities.

The lead for the SCN is Julia Coles, Senior Network & Domain Manager –

October 2015 – Diabetes Patient Education in Thames Valley

TVSCN is delighted to launch a regional review of patient education across Thames Valley, in line with the aims of its Long Term Conditions programme – to support the adoption of patient centred care planning based on the House of Care Framework.

The report responds to current patient, provider and commissioner concerns that there is an absence of comprehensive mapping and commissioning of the wide range of education and support needed for effective diabetic self-management. We describe the current situation for diabetes patient education and set the challenges and expectations of a new perspective to help create a paradigm shift for diabetes self-management education.

Dr Kathy Hoffman, TVSCN LTC Expert Hub member and Diabetes Clinical Lead for Buckinghamshire CCG welcomed the opportunity to introduce this to colleagues aross the patch; “I am delighted to be asked to promote the Thames Valley SCN report on Patient Education for patients with diabetes. The document takes you from theory to implementation in logical steps and gives very clear guidelines on what commissioners need to look for and/or require of service providers in this critical and increasingly complex area”.

Click here to access the Thames Valley Diabetes Patient Education Review (PDF)