Long Term Conditions Collaborative: Improving Care Pathways

A resource to improve care pathways for those with long term conditions.


Improvement Actions:

  • Share information and communicate real time patient data to relevant people.
  • Be Out-of-Hours smart - understand your Out-of-Hours pathways
  • Build long term solutions into existing tools like the Emergency Care Summary, Palliative Care plans and Out-of-Hours Special Notes


For any professional delivering care in-hours or out-of-hours, whether face-to-face, by telephone or on-line, up-to-date, accurate, relevant information specific to the individual is critical to the successful outcome of the encounter. Such information must be accessible and meaningful and its sharing must be secure. Undoubtedly, the professional's experience, training and consultation skills and competencies are equally important. With this in place information sharing contributes to all six dimensions of quality of care.

Role of eHealth to support the pathway

Current eHealth objectives contribute to the Long Term Conditions Action Plan and to improvements in the pathway. eHealth aims to improve access to health information, to join-up GP and hospital information services and enable quicker access to results for lab tests and x-rays.

A key priority is the Clinical Portal Programme. A clinical portal is an electronic window that will allow clinicians to access different pieces of information about individual patients in a 'virtual' electronic patient record derived from various databases. NHS Tayside and NHS Greater Glasgow and Clyde are already implementing portal technology. Their experience is being used to inform the programme, support the delivery of portal technology across Scotland and highlight how it will benefit both work process and patient care. Easier access to information will support improved care delivery and decision making. Patients can be reassured that staff have the necessary information to be able to manage their care safely.

Unscheduled and Out of Hours Care

NHS 24 frontline staff report definite benefits from accessing patient-specific Special Notes and the Emergency Care Summary ( ECS), including the ePalliative Care Summary. This information, of vital importance in unscheduled care, improves decision making with and for people with long term conditions. The ECS is available Scotland wide to NHS 24, Out of Hours Services, A&E departments, some acute receiving units and pharmacists. It is currently being piloted with the Scottish Ambulance Service. Its dataset has been expanded to include a Palliative Care Summary which will support the Gold Standards Framework Scotland. A paper process is already in place and an electronic version is now being rolled out. This will provide an electronic platform to share anticipatory care plans that contain details of carer and key professionals, diagnosis and current treatment, preferred place of care, current care arrangements, patient and carers awareness of their condition and advice for Out of Hours services.


Primary and Community Care

The Multidisciplinary Information System ( MiDIS) demonstrator project is currently live in NHS Tayside and NHS Lanarkshire and NHS Dumfries and Galloway are testing the system to support Community Nursing Teams, Mental Health Teams and AHPs share information. A single forms library to support care plans and assessments can be shared across the various service groups enforcing common data standards and improving data quality. There are also plans in Tayside to link MiDIS to the GP record. To support GPIT in all Boards, a framework contract for GPIT will be in place in February 2010 and Boards can move over to these relevant systems from then.

Integrated Care

NHS Tayside is implementing a clinical portal that provides patient centric information for both primary and secondary care clinicians, with much of the information originating from a significant sub-set of the GP record. The portal presents this information as a virtual electronic patient record divided into logical panels or portlets.

NHS Ayrshire and Arran have developed an effective system for identifying and tracking people with long term conditions who are at high risk of readmission to hospital. When people are admitted to hospital, their GP Practice is informed within 24 hours, meaning that the person's care can be better coordinated and their discharge from hospital better planned. People have had their length of stay reduced and been able to safely and quickly return to their care at home.

Ambulatory Care

NHS Greater Glasgow and Clyde has implemented a clinical portal in their new Ambulatory Care Hospitals. It supports the whole patient pathway by removing information silos and provides easier access to information. The portal will be combined with a scanning and electronic document management solution to provide a "paper-light" environment.

Patient eHealth

This will support the long term conditions work through better involvement of people in their care, better access to information to support self management and to provide education support for staff to improve health literacy. Projects include; NHS Inform, which is being led by NHS 24 and will support improved access to trusted sources of Health Information via the internet. NHS Education for Scotland have also been developing educational support approaches for the knowledge worker role.

NHS Ayrshire and Arran is developing a portal for people with long term conditions. The project aims to develop a model for engagement and secure access, to meet the functional requirements identified by patients to support them to manage their health, identify the benefits and share lessons learned. The main capabilities encompass access to information both from NHS records and trusted sources on health, diseases and their treatment options, as well as the ability to access services and utilise electronic communication channels. The priority is for people to be able to personalise their own portal. The patient portal project will include a pilot of eCorrespondance in order to support improved communication with patients.

Learning from these and other established projects such as the Renal View patient portal, will help to shape future direction of patient eHealth.

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