Professor Sally Singh, Managing Chronic Disease theme lead, presentation at the NIHR CLAHRC East Midlands launch event 14 February 2014, Loughborough.

1. Managing Chronic Disease
Sally Singh, Theme Lead, MCD Theme
CLAHRC East Midlands is hosted by
Nottinghamshire Healthcare

2. Background
15.4 million people in England have a long term condition
People with long term conditions use a significant proportion of health care
services (50% of all GP appointments and 70% of days spent in hospital beds), and
their care absorbs 70% of hospital and primary care budgets in England.
Cardiovascular diseases account for most deaths (17.3 million worldwide),
followed by followed by cancers (7.6 million), respiratory diseases (4.2 million),
and diabetes (1.3 million).
They share four risk factors: tobacco use, physical inactivity, the harmful use of
alcohol and unhealthy diets.

3. Outcome frameworks

4. Overarching indicators
• Health-related quality of life for people with long-term
conditions
• Improvement areas
• Ensuring people feel supported to manage their LTC
• Improving functional ability in people with LTC
• Reducing time spent in hospital by people with LTC
• Enhancing quality of life for carers

5. Why us?
Strong track record of research and innovation
Excellent research infra-structure across the EM
(Biomedical Research Units)
National Centre for Sports and Exercise Medicine

6. Our proposed areas of focus
• Long term conditions• the use of IT systems to support decision making and delivery of
care (diabetes and chronic kidney disease)
• interventions designed to support and educate patients
(COPD and cardiac disease).
These are components of an integrated care pathway that
personalise and stratify care appropriately; an important feature
of the overall strategy to manage chronic disease

7. Our projects (1)
To develop an effective primary care intervention to reduce
mortality and morbidity in patients with type 2 diabetes and
(Kamlesh Khunti Leicester &Nadeem Qureshi, Nottingham).
• An intervention at GP level using GP computer prompts in
conjunction with enhancing the skills of key practice staff, with
the aim of supporting individuals with microalbuminuria and
diabetes, who are at high risk of CVD and CKD.
• To test for feasibility and generalisability of this approach in the
East Midlands.

8. Our projects (2)
• The IMPAKT CKD tool (Nigel Brunskill)
IMproving Patient care and Awareness of
Kidney disease progression Together
Aim - to use a primary care
informatics solution to identify
patients with chronic kidney disease
(CKD) and other long term conditions
in primary care who are at risk of
AKI, needing unscheduled care or
acute admission.
- to deliver a self-management
intervention to prevent admission.

9. Our projects (3)
• Self management - for COPD (Sally Singh & Katy Mitchell)
• Previously tested a supported self management approach
• Aim - to test wider roll out and local delivery based in primary
care

10. Our projects (4)
•
Maintenance post cardiac rehabilitation (post MI patients)
To determine whether implementation of a structured education and physical
activity programme in primary care, to people who are at high future risk of diabetes
following a myocardial infarction, will reduce cardiovascular risk and dysglycaemia
•
Use of technology in cardiac rehabilitation (web based intervention)
To determine whether a Web-Based Cardiac
rehabilitation programme is a realistic
alternative for those declining or dropping
out Of conventional rehabilitation

11. Thank you
MLTC theme contact: sally.singh@uhl-tr.nhs.uk
www.clahrc-em.nihr.ac.uk
@CLAHRC_EM
This research was funded by the National Institute for Health Research Collaboration for Leadership in Applied
Health Research and Care East Midlands (NIHR CLAHRC EM). The views expressed in this presentation are those of
the speaker(s) and not necessarily those of the NHS, the NIHR or the Department of Health.