Hertfordshire and West Essex Integrated Care Strategy

Strategic priority 5: improve support to those living with life-long conditions, long term health conditions, physical disabilities, and their families

We will support people living with lifelong conditions, long term health conditions, physical disabilities and their families assisting them to take more control of their health and live a good quality of live.

Where we are now
  • People with long-term conditions are two to three times more likely to experience mental health problems.
  • 27.5% of the Hertfordshire and west Essex population are estimated to be living with a long-term health condition.
  • £7 out of every £10 spent in the NHS is spent caring for people with a long-term condition.
  • Physical disability is defined as a “limitation on a person's physical functioning, mobility, dexterity or stamina” that has a “'substantial' and 'long-term'” negative effect on an individual’s ability to do normal daily activities. (Equality Act, 2010). Approximately 6% of the HWE population consists of adults with a serious physical disability. With 14.3% of people having their day-to-day activities limited by their health (based upon Hertfordshire data).
  • There is potential underdiagnosis for a range of long-term conditions, particularly hypertension and chronic kidney disease.
  • Rates of emergency admissions are high for COPD (East and North Hertfordshire, and South and West Hertfordshire), coronary heart disease (South and West Hertfordshire, and West Essex) and heart failure (South and West Hertfordshire).
  • Outcomes are worse, relative to the ICS average, in areas with higher levels of deprivation (Broxbourne, Harlow, Stevenage, Watford and Welwyn Hatfield).
  • Services are not always person-centred in a way that allows individuals to become involved in decisions about their care. The model of care needs to move away from a disease-specific model to a more integrated approach, considering all existing conditions, ‘risk of’ conditions and the wider determinants of health that can impact on an individual.
Outcomes we want to achieve

We want people to be able to say:

  • I feel supported to manage my long-term health condition or disability and the care I receive is co-ordinated.
  • I understand my condition, feel in control of my care, and know where to go for help and can access support when I need it.
  • I can care for my own health as well as the person that I care for.
  • I can plan my care with people who work together to understand me and my carer(s), allow me control, and bring together services to achieve the outcomes that are important to me.
  • I can access services and support.
What will change

We will:

  • Work more effectively as a system to develop and provide joined up integrated health and care services and facilities to support those living with long-term or lifelong conditions or physical disability.
  • Ensure robust and seamless transition pathways into adulthood that promote choice and independence.
  • Support and empower people with long-term health conditions, physical disabilities, and their carers, to live healthily and independently, with better control over the care they receive.
  • Support engagement in person-centred care through a range of activities including identifying and supporting champions to be local change agents.
  • Work with our population, particularly those who are not currently accessing services, to lower risk factors and improve detection, diagnosis, and earlyintervention for those developing long-term conditions. This includes delivering annual health checks for people with severe mental illness, learning disabilities and autism.
  • Support our residents with physical disabilities, including neurological conditions, to improve their physical health and access preventative health services.
  • Ensure women are supported through the menopause and encouraged to take up activities and use medication (where appropriate for their needs) to counteract the impact of hormone deficiency thereby reducing risks of cardiovascular disease, dementia and hip fractures in later years. Women’s Health Strategy for England
  • Increase the number of residents who receive NHS health checks, including annual health and physical checks for those with a severe mental illness (SMI) or learning disability (LD) and annual reviews for residents that are frail or at risk of frailty.