We must do more to address this imbalance. We aim to deliver real change, using insights from our linked data & practical work with our health and care system to ensure population health is for everyone.

What are Long Term Conditions?

Long-term conditions or chronic diseases are conditions for which there is currently no cure, and which are managed with drugs and other treatment, for example: diabetes, chronic obstructive pulmonary disease, arthritis and hypertension.

Long-term conditions are more prevalent in older people (58% of people over 60 compared to 14% under 40), in more deprived groups (60% more people in the poorest social class than the richest social class and 30% more severity of disease) and among black people. 

What are we doing about it?

Care City is based in London's poorest borough and exists to improve health and the determinants of health. That means it’s our job - in partnership with many others - to tackle poverty and racism, and the insidious connections between them. Across our work, we seek to open up access to healthcare, and lower barriers of stigma, language, place, cost and culture.

Through our Care City Cohort linked dataset (data from across 5 settings of care - hospital, primary, community, mental health and social care), we can see the part that race and racism plays in il-health. We will keep measuring and sharing this gap, and we hope to see it close.

As an organisation, our mission is not defined by racial injustice, and we don’t seek to pretend otherwise. However, unless we stand together with people and partners across Barking and Dagenham to tackle it, we cannot hope to achieve the mission that does define us; creating a happier, healthier older age for everyone.

For an example of our work to open up access to healthcare for people with long-term conditions, read here about our Test Bed programme.

Using a smartphone app to facilitate better care coordination for patients with long term conditions

In partnership with Healthy.io we are testing several new technological solutions to facilitate better care coordination as well as  prevention and management of chronic disease for residents of East London. Working collaboratively with personal carers, general practice, community nursing teams and nurses, we are testing the use of smartphone cameras as portable testing devices.

People with long-term conditions are significant users of both health and social care services: for every £10 spent on health and social care, around £7 is spent on people with long-term conditions. They also account for around 50% of all GP appointments, 64% of all outpatient appointments and 70% of all inpatient bed days*.

As a healthy ageing innovation centre, our mission is to transform the health and wellbeing of our east London population who generally live shorter lives and live more of these years in ill health compared to the national average. This mission has resulted in a partnership with healthcare technology company Healthy.io, embarking on a joint program to assess different technologies with the potential to aid the ageing and caregiver communities. 

This partnership began one year ago with the stated mission of detecting and preventing long term conditions by educating and supporting both paid and unpaid caregivers with new technology to improve health outcomes across the East London population. The partnership is currently examining three key services that empower patients, medical professionals and caregivers by using the smartphone camera as a portable testing device: urinalysis, Chronic Kidney Disease (CKD) screening, and wound management. 

• Carers in 3 care agencies in East London have been extensively trained to use Healthy.io’s 10 parameter urinalysis dipstick, providing GPs with a rich dataset of results upon which they can decide to intervene in patient care. 
• 4 local GP practices have partnered with Healthy.io to facilitate screening for CKD among high-risk populations using Healthy.io’s home ACR testing kit. According to a YHEC study published in 2018, using the kit among at-risk populations could prevent 11,376 cases of end-stage kidney disease and identify 276,790 cases of undiagnosed kidney disease within 5 years. 
• Working with NELFT District Nurses in Hawkwell Court to explore new ways of assisting tissue viability nurses to monitor and assess wounds.  

Hannah Harniess, Deputy Chief Executive, Care City commented “Technology which can help GP’s, carers and nurses more accurately monitor and manage the health of their patients and provide pro-active and rapid treatment and support can not only reduce cost burdens on the NHS, but improve health outcomes for the patient. We are therefore delighted to be able to support NELFT and Healthy.io to implement and evaluate the use of this digital technology in our East London communities.”

Katherine Ward, Chief Commercial Officer and European GM, Healthy.io, said: “We are delighted to partner with Care City and to provide local healthcare professionals with new tools to improve care for the community in East London.”

*Long-term conditions compendium of information third edition Department of Health 

Putting the people at the heart of decision making, to support the transformation of health and social care services in East London.

The Community Board will represent the patient, carer and public within Care City’s decision-making processes. Community Board members will shape, review and challenge Care City’s work and provide an independent perspective on operational and strategic issues. It will also give opinion and advice on topics such as:

• Engaging with patients and the community in ongoing dialogue
• Demonstrating impact, outcomes and success for population
• Being accessible and inclusive of diverse communities and groups

The new Community Board comprises eight members representing a number of backgrounds, ages and experiences. They will meet bi-monthly and collaborate with Care City’s Executive Board, to ensure the development of a truly robust and effective strategy for transforming health and care services in its East London geography.

Jenny Shand, Executive Director, Care City commented “They are a diverse group, yet all Community Board members share something in common. They are passionate about improving health and care services and want to help Care City to deliver tangible benefits to our local people”

Sandra Rennie, Community Board member commented “I live with a long term health condition, it impacts my day to day life and as a result I use many health and care services. Based on this lived experience of interacting with these systems, I feel I can identify areas where improvement is required. Having a voice on the Care City Board gives me an opportunity to share these ideas. I feel closer to where decisions are being made and over time will see impact of the work that we do together”

Ray Glazer commented “I was recently asked why I wanted to be involved in the Board - what I felt I may get out of it. My answer is simple…having an opportunity to make people’s lives better – what could be better than that?”

The first Community Board meeting took place on 25^th September.

A partnership between Feebris and Care City has been announced as one of 18 digital solutions that have been awarded funding under the Techforce19 challenge to roll out the Feebris app to care homes in East London to support their residents.

The TechForce19 programme is an NHSX Covid-19 response initiative, supported by PUBLIC and the AHSN Network, focussed on creating a pool of technologies that have the potential to rapidly scale regionally and nationally.

Feebris is a London based health AI company, developing deep tech that helps vulnerable patients get early access to care. The company first developed its AI-powered platform to help community workers in India detect childhood pneumonia. The platform has since evolved to help carers and health assistants identify health risks and deterioration within elderly communities. This technology enables vulnerable individuals to still receive quality care whilst staying safe and isolated during the pandemic.

The Feebris app guides a carer through a 10-minute check-up, including capture of vital signs from connected medical-grade sensors (such as digital stethoscope and pulse oximeter). Feebris uses artificial intelligence to help carers triage their patient’s day-to-day needs, and supports GPs remotely assess their patient’s condition

Care City, a healthcare Community Interest Company with a track record of integrating innovation into health and care settings, has already been working with Feebris, to introduce its technology to thirteen care homes in Barking & Dagenham, Havering and Redbridge. However, this funding from Techforce19 will see the technology introduced to another ten across East London.

Adam Bacon, Co-Founder and COO, Feebris commented “With patients and clinicians isolating, the pandemic has brought into focus the need for precision medicine in the community. It is important that we act now to continue meeting the existing and emergent healthcare needs of vulnerable patients in isolation. We are privileged to receive the support of organisations like Care City and now the TechForce19 programme to deliver this mission.”

John Craig, Chief Executive, Care City commented “Our health system and innovators across the world are working at speed to identify, design and develop solutions to help fight coronavirus. We are delighted that Care City and Feebris have been selected from over 1600 innovations to take part in a rapid testing phase to meet this pandemic challenge. Enabling a carer to collect observations and lung sounds and share them with a patient’s GP enhances the virtual ward rounds that are rapidly being set up and allows the GP to focus where they can most help.”

We're delighted to be working in partnership with North East London Foundation Trust (NELFT), Essex Partnership University Trust (EPUT), UCLPartners and XIM is testing a new and improved method of monitoring and measuring physical health for patients with mental illness.

The health disparity faced by people with serious mental illness is well documented, as are the multiple contributing factors for this. NELFT and EPUT are committed to maximising opportunities for their mental health staff to support people to improve their physical health alongside their mental health. Digital technology offers a potential tool to support staff, build confidence in physical health assessment and ultimately improve outcomes for our population. 

Lifelight is a software technology that allows completely contactless measurement of three vital signs (heart rate, blood pressure and respiration) in just 40 seconds using the camera built into a standard tablet device, with no additional hardware, making the process of taking vital signs much simpler and less distressing for staff and patients. We anticipate that implementing this technology will enable staff to gain confidence in physical health monitoring and detection, better supporting people to look after themselves, improve their health and prevent avoidable health problems.

The project will evaluate the effectiveness of the tool as well as service users', their carers' and staff acceptability of such digital contactless vital signs technology use on mental health wards. The aim is to reduce the distress and discomfort of having vital signs taken in comparison to current methods, and to enable mental health professionals to deliver more effective detection and intervention for physical deterioration or physical disease risk factors. 

Dr Caroline Allum, Executive Medical Director, NELFT commented “We are really excited to be part of this project. This will help in situations where taking manual observations may be difficult and allow better patient care. The staff are excited to find technology that helps them in their daily work.”

Hannah Harniess, Deputy Chief Executive, Care City commented “People with long-standing mental ill health often suffer a greater burden of physical health conditions. Technology which can help staff better monitor and manage physical health during an acute mental health admission could contribute significant steps towards addressing this disparity. We are therefore delighted to be able to support NELFT and EPUT to implement and evaluate the use of digital technology to improve physical monitoring of mental health in-patients.”

Dr Kallur Suresh, EPUT’s Deputy Medical Director, said: “We are delighted to have the opportunity to test the use of this exciting technology in our care for people with mental ill health. It is very important that we look after people’s physical health as well as treating their mental health conditions. This innovation has the potential to improve people’s health outcomes – as we could better monitor any deterioration in their health – and also improve their experience of care.”

Professor Mike Roberts, Managing Director, UCLPartners AHSN commented “The NHS Long Term Plan challenges us all to implement new technologies that provide solutions to key clinical challenges. This exciting programme is one such innovation that will help us develop a technologically enabled workforce to meet the needs of our patients today and tomorrow.”

Care City has been selected by the Health Foundation, an independent charity, to be part of its programme to help research teams bridge the gap between academic research findings and actionable learning for people practising in health and care.

Having previously received funding from the Health Foundation, the team from Care City will now be able to use innovative and creative approaches to translate their findings into practical tools for practitioners in health services and health policy.   

The team will receive up to £50,000 for the development of tools and resources to support the implementation of their findings into practice, and to develop innovative ways to promote their findings to those who influence, plan and deliver health and care services. The project will be funded for between 12 and 14 months. 

Across Barking and Dagenham, Care City has used joined up data to better understand population characteristics and behaviours, and how people use services. Through an Advancing Applied Analytics project, the impact of social isolation on health and care utilisation was explored, using an existing linked dataset. 

For example, the research into people living alone found that they had a higher use of services across all care settings. These findings are important, but they are also easy to misunderstand. Care City want a deeper understanding of the issues - including through qualitative work with the people concerned - before recommendations are made about provision. This programme will enable that deep work and give Care City the time and space to share it with decision-makers. 

The work on living alone is one of numerous studies using the Care City local dataset which could benefit from translational work for local policy audiences. However most recently the data has been used to pro-actively help with the current COVID-19 crisis. 

Councillor Maureen Worby, Barking and Dagenham Council’s Cabinet Member for Social Care and Health Integration, commented: “The Care City joined dataset has really proved its worth 10 times over during the current crisis. Just before lockdown the council used the dataset to identify high priority areas to target using key health and demographic data. This resulted in a hotspot priority map which was used by council teams in partnership with local voluntary organisations to mobilise volunteers to these areas to leaflet, offer assistance and raise awareness. We produced the maps within two hours and our volunteers were on the ground within two days from the initial request”. 

John Craig, Chief Executive, Care City commented “This project will provide resources for policy makers and commissioners that describe the evidence base, deepen understanding of the data, and familiarise them with simple analytical approaches”. 

Shaun Leamon, Research Manager at the Health Foundation, said: “We are very pleased to be funding the four selected projects for this round of the Evidence into Practice programme, which will result in resources being developed that will provide actionable tools for those working in practice or policy to implement change, and will have an impact on the improvement of health or social care services in the UK.”