A total of 15 million people in England (around 30%) live with long term conditions (LTCs), and the proportion with multiple LTCs is increasing dramatically.
LTCs are the most common cause of death and disability. People with LTCs account for:
- 70% of the money spent on health and social care
- 55% of GP appointments
- 68% of hospital outpatients
- 77% of inpatient episodes
Most people with LTCs spend just a few hours per year with healthcare professionals and more than 99% of their lives managing their conditions themselves. As such, they need to become experts in their own health and will make all day-to-day decisions which affect their own health.
For healthcare this means the system needs to support individuals to develop the knowledge, skills and confidence to manage their own care.
The case for self-management
There is an extensive evidence base for the outcome and cost effectiveness of interventions which support self-management. The chronic care model (Wagner, EH, Austin BT, Von Korff, M. [1996] ‘Organising Care for Patients with Chronic Illness’) describes how better outcomes for people with LTCs can be achieved when there is partnership working between an ‘engaged’, ‘empowered’ or ‘activated patient’ and an organised proactive healthcare system.
It has been suggested that the most important element of this complex intervention is support for self-management. Self-care is one of the best examples of how partnerships between the public and health service can work – for every £100 spent on encouraging self-care, around £150 worth of benefits can be achieved in return (Wanless D. [2002]. ‘Securing Our Future Health: Taking a Long-Term View’ final report, HM Treasury).
What does this mean for patients?
Person centred care planning enables an individual to identify their own goals, action plan and any support they may need through preparation and personal ownership alongside the more traditional element of clinician/patient consultation.
Supporting people with long term conditions by increasing their knowledge, skills and confidence to self-manage has benefits for everyone:
- better health outcomes
- improved experience for service users
- services and resources are used more effectively
Strategic Clinical Network (SCN) contribution
Person centred care/personalisation as exemplified through shared decision making, care and support planning are not new concepts. The NHSE Universal Personalisation model (2019) brings all these elements together in a single overarching programme supported by the Personalisation Institute of accredited trainers and training.
Person centred care initiatives have been in place within our Clinical Networks for some years. With the establishment of the national personalisation programme with regional NHSE teams and a range of SE wide networks and collaboratives supporting this work, the role and contribution of South East Clinical Delivery and Networks has changed.
WASP programme (Wessex Activation and Self-Management Programme)
Initially funded by the Wessex SCN, WASP continues as an active programme focused on Hampshire and Isle of Wight. The programme has strong links with both the regional personalisation team and the local STP. It is led by a network of people from health, social care, commissioning, and third sector backgrounds.
The focus is on the promotion and adoption of PAM (Patient Activation Measure) and working with teams to support a person centred approach to care using the COM-B model.
This programme is now hosted on the HIOW STP website, where a range of information, resources and contact details can be found.
Thames Valley SCN Care and Support Planning (CSP) Programme
This programme started in 2014 with the mandate of all the Thames Valley CCG accountable officers. It was jointly funded between Thames Valley SCN and Health Education Thames Valley. The focus is to support colleagues in primary care adopt CSP, based on the Year of Care model, for people with long term conditions. There is a wide range of information and resources on the Year of Care website.
To date over 95% of GP practices in Thames Valley have completed the core training, all the CCGs have invested in facilitators to work with and support practices, and the approach has been expanded across a range of LTCs. Many practices are now keen to move to a multi-morbidity approach.
The range of support and resources now includes:
Training
Training is accessed through individual discussions with your CCG CSP facilitator, and on the ICS training hub website. A range of workshops are available:
- CSP taster session
- CSP core training – a day and a half course for practices new to CSP
- One day CSP – for HCPs new to working in a CSP practice
- Team workshop – half day for wider practice team
- Moving On – a half day workshop for practice teams to move to a multi-morbidity approach
Resources
- Post training implementation- practice pack, resources and templates- a secure weblink for these resources is provided to colleagues at time of training or can be accessed via your CSP facilitator.
- CSP for people with dementia – you can download the toolkit here.
- Year of Care has a wide range of information and resources
- Dietary resource for HCPs, supporting patient choice for those with type 2 diabetes – you can download the resource pack here.
Support
- CCG based facilitators for CSP remain in post and are the first point of contact for practice colleagues.
- Thames Valley pool of trainers accredited by Year of Care are available to deliver training – via the facilitators.
This programme now sits with the BOB STP as part of the Personalisation Programme. The point of contact is Steve Goldensmith, Head of Long Term Conditions, Bucks CCG, email: steve.goldensmith@nhs.net
Resources
