Long Term Conditions



Project Aims

  • Review LTC commissioning and provision for CYP across Yorkshire & the Humber. 
  • Identify Best Practice for management of asthma, epilepsy and diabetes and to support a system wide reduction in unplanned emergency admissions.

In November 2013 as part of the work programme Y&H Children’s SCN began to develop a focus on children and young people with long term conditions (LTCs), in particular for CYP living with asthma or epilepsy.  

In order to develop a scope for this work and support commissioners and providers across the region, it was important that we had a clear understanding of the priorities and challenges in relation to asthma and epilepsy.  Gathering this information enabled the SCN team to develop a project overview and identify key themes and how the SCN can provide valuable clinical expertise, knowledge and insight to inform commissioning and provision of services across Y&H.


What has happened/What we did...



Scoping: The SCN conducted a series of one to one meetings with CCG Commissioners, Providers, and stakeholders across the region and Asthma UK in order to understand the current landscape and context for Asthma Provision.  9 CCGs (representing 13), Respiratory Team at Leeds Teaching Hospital Trust, Wakefield Public Health Respiratory Lead and 7 SCNs shared their work and progress in relation to Asthma.


Data and Intelligence:  The SCN business intelligence team undertook a search for available asthma data to support the scoping and commissioners across Y&H. 




Scoping: The aim of the Epilepsy scoping project was to understand and review:

-       Commissioning of service across Y&H for CYP living with Epilepsy
-       Provision of services for CYP across Y&H living with Epilepsy. 
-       Identify Best Practice for management of Epilepsy.
-       Develop recommendations on how the SCN for Children can support and improve the commission and provision of Epilepsy services in Y&H


The scoping was undertaken by questionnaire circulated to CCGs and providers.

Responses were received from thirteen of twenty four CCGs and ten of fifteen providers. Epilepsy was identified as a priority for 9 of the 10 providers and for 4 of the CCGs.

The epilepsy report (see achievements below) provides the current position, results and recommendations as a result from the scoping.



Meetings and Stakeholder Engagement



Stakeholders where engaged across providers and commissioner via one to one meetings. (See scoping above)

National work: Y&H SCN work was linked with the National Paediatric Asthma Initiative (NPAI). The overall aim of the NAPI was to improve the commissioning, design and delivery of services for children with asthma. The NAPI was launched in 2014 and was a collaborative of professionals from across NHS England, Strategic Clinical Networks, Clinical Leads, Academic Health Science Networks, respiratory networks, professional bodies and third sector organisations who have a responsibility for improving outcomes for children and young people with asthma.




Stakeholders were engaged via questionnaire. 

Worked in partnership with Epilepsy UK


Achievements and Outcomes



Asthma Report and Epilepsy Report: The purpose of these documents was to share the insight and feedback provided by Y&H stakeholders from the scoping.

To provide local and national evidence and ambitions in order to develop and define priorities and recommendations, including where working collaboratively across Y&H would assist in a system wide reduction in unplanned emergency admissions for CYP living with Asthma.

The reports were shared with stakeholders and the asthma report formed the basis of the Asthma Workshop held on 17th July 2015.


Asthma Services and Management Workshop:  At the request of commissioners the Y&H SCN hosted an Asthma Services and Management Workshop on Friday 17th July 2015 at the Met Hotel, Leeds.  30 delegates attended the event with representation from Commissioners, Primary and Secondary Care, Community Services, Public Health, School Nurses and colleagues from other SCNs. The evaluation and feedback from the event was extremely positive


Asthma Services and Management Workshop Report: The purpose of this document is to share the feedback and evaluation from the Y&H Children’s SCN Asthma Services and Management Workshop 17th July 2015, including: feedback from all the workshops and presentation, the overall evaluation and recommendations for taking this work forward across Y&H.  The report has been disseminated to all delegates who attended the event and was presented at the Y&H C&M SCN Commissioners Forum on 2nd September 2015

To provide local and national evidence and priorities/ambitions in order to develop and define priorities and recommendations where working collaboratively across Y&H will assist in a system wide reduction in unplanned emergency admissions for children and young people (CYP) living with Epilepsy.





Asthma Services and Management Workshop 17th July 2015 (see achievements above)







  • Epilepsy Report  - includes a list of key documents
  • Epilepsy Commissioning Toolkit: Epilepsy Action and Epilepsy Society have worked with nine Clinical Commissioning Groups (CCGs) to create a single access point of resources to support effective commissioning for children and adults with epilepsy.   The nine sections work through the whole commissioning process. Click here to access the resource.

Each section can be accessed individually to meet an organisations specific need.

Support for the following elements can be found in the toolkit:

-       Scope – What needs to be done
-       Data Analysis
-       Map Current Provision
-       Co-production
-       Service Model
-       Business Case
-       Service Specification
-       Contract Service
-       Implementation