Improving management of long-term conditions in the East of England

More than 15 million people in England suffer from one or more long-term health conditions. For some people, these conditions go unmonitored and unmanaged until a hospital visit becomes necessary, which can disrupt staffing levels and postpone or cancel scheduled operations.

10% of patients with long term conditions who are admitted to an acute hospital account for 55% of hospital stays. In 2005, The NHS committed to the number of Community Matrons to 3000. It soon became apparent that the role was varied and embraced the work of community and district nurses, physiotherapists, and other people working in social care.

The aim was to offer proactive long-term condition management in the home, to identify potential complications at an early stage, and to reduce upset and discomfort to the patient. The challenge was to define the role and remit of a health worker managing long-term condition cases and to develop training modules that would fill any skill gaps.

Working with the Department of Health, our team examined its database of competences and arrived at several areas or “domains” that would standardise the role throughout England.

East of England Strategic Health Authority (SHA) saw the Skills for Health draft competencies as fundamental to its own strategic framework for case management. In Essex, all 75 community matrons and case managers are undertaking blended learning modules in a portfolio provided jointly through Essex University and Anglia Ruskin University. The modules have been specifically designed to meet the requirements of the national competency framework for Community Matrons and Case Managers, and provide academic credits towards a Masters degree.

“Our Community Matrons and Case Managers are much more confident in their role and feel that they are part of a group trailblazing a new way of working – so it’s been effective psychologically as well as on a technical skill level. The competency framework has been so valuable in shaping the proactive aspect of the community matron role.”

Paul Taylor Deputy Head of Education and Development,
East of England Strategic Health Authority

A key aim of Skills for Health is to develop and manage a bank of national workforce competencies that describe the performance criteria, knowledge, and understanding required to carry out a work activity effectively. Because competencies describe what individuals need to know and to do, regardless of who is performing the activity, they can be used in many ways.

The Benefits

• Patients receiving more regular care not just at times of GP visit or emergency
• Increase in patients managing their own conditions with support at home and reduction in calls for emergency services
• Reduction in the risk of further complications in long term conditions
• Release of hospital beds enabling more effective use of resources and reduction in waiting times for urgent cases
• ‘Blended’ learning options reduce training costs and time away from patient care
• Learning modules providing recognition as part of a national framework and evidence of CPD for regulatory and professional nursing bodies

Using a consistent, competence-based approach has resulted in the role being established as standard throughout England. It is also being examined in Wales, Northern Ireland, and Scotland for potential adoption.

As the Sector Skills Council for the UK health sector, we support the NHS, independent healthcare providers and voluntary organisations. Our purpose is to help develop solutions that can deliver a skilled and flexible workforce to improve health and healthcare.