Improving the health and well-being of people with long

Improving the health and well-being of people with long term conditionsWorld class services for people with long term conditions –information tool for commissioners

DH INFORMATION READER BOX

PolicyHR/WorkforceManagementPlanning/Clinical

EstatesCommissioningIM&TFinanceSocialCare/PartnershipWorking

Document purpose Forinformation

Gateway reference 12121

Title Improvingthehealthandwell-beingofpeoplewithlongtermconditions

Author DH/LongTermConditions

Publication date January2010

Target audience PCTCEs,NHSTrustCEs,SHACEs,MedicalDirectors,DirectorsofPH,DirectorsofAdultSSs,DirectorsofHR,DirectorsofFinance,AlliedHealthProfessionals,GPs,CommunicationsLeads,DirectorsofChildren’sSSs,VoluntaryOrganisations

Circulation list

Description ThemainaimoftheinformationtoolistoshareacommonvisionofwhatagoodserviceforpeoplewithLTCs,andtoprovidesomepracticalsuggesstionsforcommissionerstohelpthemachievethatvision.

Cross reference N/A

Superseded documents N/A

Action required N/A

Timing N/A

Contact details LongTermConditionsRoom2N16,QuarryHouseQuarryHillLeedsLS27UE

For recipient use

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CONTENTS

Foreword 2

Executive summary 3

1: Purpose of this document 4 -Context 4

2: What is a good service? 6 -Whatdoesgoodlooklikeforpeoplewithlongtermconditions,

theircarersandfamilies? 9 -Whatdoesgoodlooklikeforprofessionals? 9

-Whatdoesgoodlooklikeforcommissioners? 11

3: Commissioning a world class long term conditions service 16 -Commissioningpersonalisedcareplanningandselfcaresupport 19 -Conclusion 28

Annex A–TopTipsindetail,includingexamplesofovercomingbarrierstodelivery 30

Annex B–Linkedpoliciesandinitiativeswithsupportinginformation 51

Annex C–Glossary 62

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Foreword

TheDepartmentofHealth’sstrategyforlongtermconditionsaimstoputpeoplewithlongtermconditionsatthecentreofdecisionmakingabouttheirowncare.Inthisway,theywillpersonalisetheservicestheyneedsothattheyaretrulysupportedtolivelifeastheywant.Thisshouldresultincarebeingdeliveredinthemost

appropriatesettingfortheperson’sneeds.Inmanycases,thiswillbeasclosetohomeaspossibleandmainlyinaprimarycaresetting.

Deliveringhealthandwell-beingimprovementsforpeoplewithlongtermconditionsischallenging:itisn’tjustabouttreatingillness,it’saboutdeliveringpersonalised,responsive,holisticcareinthefullcontextofhowpeoplewanttolivetheirlives.Therearehugebenefitsforeveryoneingettingitright–fortheNHS,localauthorities,thethirdsectorand,mostofall,forthosepeoplewhoselivescanbetransformedbybeinggiventhesupportthat’srightforthemandproportionatetotheirneeds.Itisthereforecrucialtoplanaccordingly,ensuringanefficientuseofhealthandsocialcareresources.

Improving the health and well-being of people with long term conditionsisintendedtobearesourceforreflection,challengeandpracticechange.Thetoolhasbeendevelopedtoprovideinformationandrecommendactionsforcommissionersandlocalpartnerstoconsiderwhendevelopingcommissioningstrategiestomeettheneedsofpeoplewithlongtermconditions.

Ann KeenParliamentaryUnderSecretaryofStateforHealthServices

Executive summary

Ifbettermanagementoflongtermconditions(LTCs)istobeachieved,thentransformationalchangeisrequired–bothwithinthesystemand,thisisperhapsmorechallenging,tothecultureandbehavioursoftheworkforce,peoplewithLTCsandthepublic.ThepersonalisationaimsofLTCspolicyhavelongbeentalkedabout,butchangeisnothappeningfastenoughandfundamentalbarrierspersist.Localhealthandsocialcaresystemsneedtoworktogethertoidentifywhatworkswellandtopromulgategoodpracticetoreducevariation.

Thisdocumenthasbeenco-designedwiththeNHSandsocialcaretoprovideinformationthatwillhelplocalpartnerstocommissionworldclassservicesforpeoplewithLTCs.ThemainaimthroughoutthedevelopmentofthisdocumenthasbeentoshareacommonvisionofwhatagoodservicelookslikeforpeoplewithLTCs(includingchildrenandyoungpeople),theircarersandfamilies,andtoprovidesomepracticalsuggestionsforcommissionerstohelpthemachievethatvision.Itsetsoutsomeappropriateactionsforcommissionerstoconsiderateachstageofthecommissioningcycle,tosupportimplementationofpersonalisedcareplanningandselfcaresupportforpeoplewithLTCs.

Anumberof‘roadblocks’toachievingworldclasscommissioninghavebeenidentifiedandsetoutinAnnexA.Ineachcase,examplesofhowcommissionershavedealtwiththose‘roadblocks’havebeenprovided,and10‘TopTips’havebeendevelopedtohelpcommissionersachieveagoodservicemodel.

TheinformationinthisdocumenthasbeendevelopedthroughinterviewswithpeoplewithLTCs,professionalsandmanagersfromhealthandsocialcareproviderorganisations,localauthorities,primarycaretrusts(PCTs)andpractice-basedcommissioning(PBC)groups.

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Section 1: Purpose of this documentContext

Alongtermconditionisonethatcannotcurrentlybecuredbutcanbecontrolledwiththeuseofmedicationand/orothertherapies.

Therearecurrently15.4millionpeopleinEnglandwithanLTC.Duetoanageingpopulation,itisestimatedthatby2025therewillbe42%morepeopleinEnglandaged65orover.ThiswillmeanthatthenumberofpeoplewithatleastoneLTCwillriseby3millionto18million.

People with LTCs account for a significant and growing proportion of health and social care resources. TheDepartmentofHealth’sbestestimateisthatthetreatmentandcareofpeoplewithLTCsaccountfor70%ofthetotalhealthandsocialcarespendinEngland,oralmost£7inevery£10spent.

Social care expenditure, too, is focused on those with LTCs and will be put under pressure by the ageing population. By 2022:• theproportionofthoseaged65andoverwillincreaseby

37%to10.8million

• thenumberofpeopleaged65andoverwithsomedisabilitywillincreaseby40%to3.3million

• thenumberofdisabledolderpeoplereceivinginformalcare(inhouseholds)willriseby39%to2.4million

• thenumberofpeopleinresidentialcarehomeswillincreaseby40%to280,000

• thenumberofpeopleinnursinghomeswillincreaseby42%to170,000.

This need for social care will mean that by 2022:• publicexpenditureonlongtermcarewillriseby94%to

£15.9billion• totallongtermcareexpenditureisforecasttoriseby29%to

£26.4billion.Thisisequivalenttoarisefrom1.4%to1.8%ofGDP.

The15.4millionpeopleinEnglandwithLTCs(around30%ofthepopulation)accountformorethan50%ofallGPappointments,65%ofalloutpatientappointmentsandover70%ofallinpatientbeddays.

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TheGovernment’saimistoputpeopleatthecentreofdecisionmakingaboutthecaretheyreceive.Thisfitswiththeoveralldrivetoembedpersonalisationacrossallpublicservices.Aspartofthisdrive,personalhealthbudgetsarebeingpilotedacrossthecountry,givingpeoplemoresayandcontroloverhowthemoneyfortheirhealthcareisspent.Supportingpeopletotakeamoreactiveroleindecisionsabouttheirhealthandwell-beingmeansthattheNHShastochangefundamentallythewayinwhichitbothdeliversandcommissionsservicesforpeoplewithLTCs.

CommissionersmustalsounderstandhowbettermanagementofLTCscanfullysupporttheminachievingtheaimsoftheQualityandProductivityChallenge.Inthecurrenteconomicclimate,deliveringmoreofthesameisnotanoptionandthisisparticularlyrelevanttolongtermconditions.Weknowthatmoreproactive,preventiveandpersonalisedapproachescanimprovepatientexperienceandreduceunscheduleduseofhospitalcare.Therearepotentialhugewinstobemade,buttheyrequiretransformationalchange,aninnovativeapproachwithstrong,dynamicleadershiptodrivethisforward.BettermanagementofLTCscansupportcommissionerstoachievethechallengeofqualityandproductivityinthefollowingways.

• QualityofserviceswillbeimprovedbypeoplewithLTCshavingmoreproactive,plannedcareandservicesthatmeettheirwiderholisticneedswithafocusonoverallhealthandwell-being.Peoplewillthenfeelbettersupportedtobeindependentandincontroloftheircondition.

• InnovationwillbestimulatedthroughagenuinediscussionwithpeoplewithanLTCthatcanopenupwiderchoicestomeetholisticneeds–suchasassistivetechnologies,exerciseonprescription,holisticweightmanagementprogrammes,accesstopsychologicaltherapiesoreventherapiessuchasacupunctureandmassage.Thisshouldmotivatecurrentproviderstoinnovate,andstimulatenewproviders.

• Productivity:thereareproductivitygainstobehadattheinterfacesacrosssectorsandservices,andmadethroughpeoplewithLTCshavingtheirwiderneedsmet,selfcaring,andhavingbetter-planned,proactivecare.The2008/09GPpatientsurveyfoundthatGPpracticesperformingwelloncareplanninghadfeweremergencyadmissionsandoutpatientappointmentsandslightlymoreelectivecare.

• Prevention:developingproactivecareplanning(whichincludesprovisionofinformationandsupportforselfcare)supportspreventioninanumberofways,includingslowingprogressionofdiseaseandpreventingemergencyadmissions.

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Section 2:What is a good service?AnumberofpublicconsultationssuchasIndependence, Well-being and ChoiceandYour Health, Your Care, Your Sayhaveprovidedconsistentmessagesfrompeoplewithlongtermconditions(LTCs)aboutwhatisimportanttothem.Overall,peoplesaytheywantservicesthatsupportthemtoremainasindependentandhealthyaspossible.Theywantincreasedchoice,withinformationtohelpthemmakechoicesandtounderstandandmanagetheirconditionsbetter.Theywantfarmoreservicesdeliveredsafelyandeffectivelyinthecommunityorathome,withmoreseamless,proactiveandintegratedservicesthatarepersonalisedtothemandtheirneeds.

WeknowthatpeoplewithLTCsarefrequentusersofhealthandsocialcareservices,includingcommunityservices,urgentandemergencycareandacuteservices.MoreneedstobedonetosupportpeoplewithLTCssothattheycantakeamoreactiveroleindecisionsabouttheirhealthandwell-being.ImplementingpersonalisedcareplanningwillenablepeoplewithLTCstoplantheircare,havestrategiesinplacetocopewithanyexacerbationsoftheircondition,andbeinpossessionofalltherelevantinformationtheyneedtomakedecisions.Theywillbesupportedtoselfcare,

havemoreconfidenceandcontrolovertheirconditionandunderstandtheimpactitwillhaveontheirlives.Therewillbeagenuineshifttowardsaddressingaperson’sfullrangeofneeds,includingpsychologicalandemotionalsupport,ratherthansimplyfocusingonamedicalmodel.Personalhealthbudgets,wherebypeoplearegivenmorecontrolofhowmoneyisspent,takethisonestepfurther.

Thereisevidenceforthebenefitsofcertainelementsofthecareplanningprocess,e.g.selfcareandselfmanagementreducingGPandoutpatientappointments.MostpeoplewithLTCsarekeentotakeresponsibilityfortheirhealth.Over90%ofpeoplewithLTCssaytheyareinterestedinbeingmoreactiveselfcarers,andover75%wouldfeelmoreconfidentaboutselfcaringiftheyhadhelpfromahealthcareprofessionalorpeer.Despitethis,manypeoplewithLTCshavelimitedknowledgeof,orinfluenceover,theircare.

Personalisedcareplanningandselfcaresupportworktogetheraspartofoneprocessofcaredeliverythatpromotespatientempowermentandchoice,supportingpeopletobemoreindependentandincontroloftheir

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conditionsandtobecomemoreactivelyengaged.Personalisedcareplanningandselfcaresupportthewidergoals,embeddingpersonalisationacrosshealthandsocialcareservicesandunderpinningexcellentmanagementofLTCs.Implementingthesepolicieswillhelptoachieveagoldstandardvisionforpersonalisedcareandtostandardisethisacrossthecountry.Itisimportant,however,thattheyarenotseeninisolationandthatcommissioningservicesandprovidersunderstandhowtheyarealigned.

PersonalisedcareplanningunderpinsexcellentmanagementofLTCsandendoflifecare,andcompletelysupportsthekeythemesdescribedinCommissioning for Health and Well-being,ourvisionforworldclasscommissioning,Putting People FirstandHigh Quality Care for All,including:

• moreindividualisedservices• morefocusonpreventionofdiseaseandcomplications• greaterchoice–includingsupportingpeopletomake

healthierandmoreinformedchoices• reducinghealthinequalities• providingcareclosertohome.

Genuinechoicesmadethroughpersonalisedcareplanningshouldleadtobetter-informedneedsassessments.Collectingandaggregatingdatafromcareplans,includingservicespeoplearerequestingthatcouldbebeneficialandaffordablebutthatarecurrentlynotavailable(unmetneed),willhelpcommissionersdelivertheservicesthatpeopleactuallywant,andwillhaveapositiveimpactontheiroverallhealthandwell-being.ThiscouldmeandecommissioningservicesthatareneitherwantednorhavinganypositiveimpactontheneedsofpeoplewithLTCs.Commissionersinareaswherepersonalhealthbudgetsarebeingofferedwillbeabletogetanevenbetterunderstandingofwhatpeoplewant,astheywillbeabletoconsiderwhatservicespeopleprocurewiththeirbudgets–thesemaybeoutsidetraditionalNHSservices.

ThissectionprovidesanoutlineofavisionforagoodservicefromtheperspectiveofpeoplewithLTCs,theircarersandfamilies,professionalsandcommissioners.

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I am as healthy and well as I can be.

I decide what should happen to maximise my well-being together with the professionals I deal

with, both on an ongoing basis and at times of need.

I can access services at a time and place andin a language and format that suit me.

I have an ongoing and trusting relationship with the professionals I deal with.

I understand the services available to meand how to use them – including who to

call if/when my condition worsens.

I feel confident that I know what to do tomaximise my own health and well-being

e.g. this could include the potential tostay in, or return to work.

Services are efficient, with no duplication ofwork, and the professionals have the information

they need to work with me effectively.

I can access a range of services to meet myindividual needs and preferences.

What a good service looks like for people with long term conditions, their carers and families

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What does good look like for people with long term conditions, their carers and families?GoodoutcomesandexperiencesforpeoplewithLTCsincludemaximumhealthandwell-being;controloverwhathappenstothem;confidenceinmanagingtheirownconditionandinusingtheservicesavailable;goodrelationshipswithprofessionals;andaccesstoconvenient,efficientservicesthatmeetindividualneedsandpreferences.SuccessfuloutcomesforpeoplewithLTCsrequireapartnershipbetweenengaged,empoweredindividualsandaproactive,responsiveandintegratedsystem.

What does good look like for professionals?Todeliverhigh-qualityservicesforpeoplewithLTCs,itisvitalthattheworkforcehastherightskills,approachesandbehaviours.

EffectiveLTCmanagementdependsonmorethanjustprovidinginformationtoindividualsandtheirfamilies.ItrequiresasupportedprocesswherebypeoplewholivewithLTCsworktoappraisetheircurrentlifestylechoices,thinkaboutimportantgoalsforthemasindividualsandworktowardsgainingtheconfidencetoattainthese

goals.Amultidisciplinaryteamofhealthandsocialcareprofessionalsmaybeinvolvedinthisprocess,dependingonthecomplexityoftheindividual’sneed.

Theabilityofindividualstotakecontrolwilldependtosomeextentonwhatstageoftheir‘healthcarejourney’theyhavereached.SomeonewhohasjustbeendiagnosedwithanLTCwillhaveverydifferentneedstosomeonewhounderstandsandhasacceptedtheircondition,orsomeonerequiringendoflifesupport.

EffectiveLTCsmanagementwillenableindividualstobecomeexpertsabouttheirconditionandtheircare.Therewillalsoneedtobearecognitionthatanindividualisasimportantwithinanintegratedsystemasanyclinician.

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The right attitudes and behaviours, which are:• encouraging• supportive• professional• advisory• respectful.

The right skills, knowledge and competences to:• communicate effectively• identify people’s strengths and abilities• advise on access to support networks• promote choice and independence• enable people to manage identified risks• provide relevant and evidence-based information* • understand what personalisation means and how to enable personal choice.

The right approaches, systems/structures and processes in place to support:• partnership and integrated working across all agencies – health, social care, community and third sector• provision of care and services that deliver person-centred outcomes.

What a good service looks like for professionals

* For more information see Common Core Principles to* Support Self Care (Department of Health, 2008).

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ItisimportantthattheexpectationsoftheworkforcebecomepartofthecontractdiscussionsbetweenprovidersandcommissionersofservicesforpeoplewithLTCs.

What does good look like for commissioners?Goodoutcomes,valueformoneyandexperiencesforpeoplewithLTCsmustbeattheheartofcommissioning.TheoutcomesandexperiencethatpeoplewithLTCswantdeterminehowservicesneedtobedelivered,whichinturndetermineswhatserviceprovidersneedtodo;allofthisthendetermineswhatthecommissionermustdo.

Settingahighbarforoutcomesandexperiences,therefore,setsanequallyhighbarforcommissioning.ThefollowingdiagramsillustratethekeyareascommissionersneedtoconsiderwhencommissioningagoodserviceforpeoplewithLTCs,andalsohighlightthekeyelementsofhowagoodserviceshouldbeprovided.

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Services should not simply provide whatprofessionals assume that people want, or justthe same things that have always been on offer.Where possible, there should be evidence ofbenefits in terms of improvements in patientoutcomes and satisfaction, and cost effectivenessand improvements. Personal health budgets willencourage innovation by giving individuals control.

Services should provide preventativecare, e.g. innovative and holistic weight loss programming and smoking cessation clinics.

Services should provide proactivediagnosis (e.g. assessment by GPs atreligious centres; public education) andshould care for needs proactively and regularly (e.g. professionals responding to telehealth information).

Services should offer personalised careplanning to address holistic needs, withgoal setting, support for self care andpromotion of choice. Services shouldbe led by a named lead for those withmore complex needs and supportedby multidisciplinary teams.

Characteristics to aim for in order to commission a good service

Personalised

Innovativeand

responsive

Proactive

Preventative

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Services should have integratedinformation systems and joint businessand financial planning across settings,professions and organisations.

People with LTCs should co-design services;care plans should be personalised for allindividuals; service user level need data shouldbe collected and segmented (by condition,complexity, risk, behaviour) to inform providerand commissioner planning.

Services should have decisive, influentialleadership; have clear mission and vision;have user-related culture; considerevidence-based treatment; and have a belief in the power of an equalpartnership between individualand professional.

Qualities that demonstrate a good service

Shared vision and

culture

Integration

Service user

[focus]

Professionals should have the skills, approaches and behaviours to deliver personalised care planning and self care support. Clinicians should beinvolved in assessing need andco-designing services with peoplewith LTCs.

Engaged professionals

Services should have effectiveperformance and financial management;a workforce actively configured to matchneeds; and protocols used to ensureconsistent and high-quality serviceimprovements.

Goodorganisation

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Achievingtheseoutcomesandexperiencesrequireserviceswhichareproactive,preventiveandpersonalised,whichsupportselfcareandwhichmoderatethelevelofcasemanagementtotheneedandriskoftheindividual.

Deliveringsuchservicesrequiresarangeofdifferentserviceprovidersofferinginnovativesolutionsandinterventions.Providersneedtounderstandthedriveforpersonalisationandchoiceandshouldofferpersonalisedcareplanning(andjointassessmentofneedforthosewithmorecomplexhealthandsocialcareneeds)asaroutinepartofthecarepathway.Providersneedtointegrateacrossorganisations,professionsandsettingsofcare;toinvolvepeoplewithLTCs;toengagetheirprofessionals;tohaveaperson-centredculture;andtoreinforceallofthiswithrobustmanagementsystemsandprotocols.

Commissioningfortheseoutcomes,experiencesandservicesisaverycomplextask.TheTopTipsinAnnexAsetoutsomepracticalsuggestionsthatcommissionerscanfollowtotacklethechallengesitraises.Theyhavebeendevelopedusingrealexamplesofwhatcommissionershavedoneandareofferedassuggestionsforimprovinglocalservices.

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Promotes choice and control by putting the person at the centre of the process

and facilitating better management of risk

Personalised care planning

Focuses on goal setting

and outcomesthat people

(including carers) want to achieve

Is planned, anticipatory and proactive, with

contingency (or emergency) planning to manage crisis episodes better (for those

with complex needs)

Ensures that people, especially those with

more complex needs or those approaching end of life, receive co-ordinated care packages, reducing fragmentation between

services

Provides support for self care so that people

can self care/self manage their condition(s) and prevent deterioration (e.g. as set outin Your health, your way)

Facilitates joined-up working between different professions and agencies, especially between health

and social care

Provides information that is relevant, timely

and accredited to support people with decision making and choices (e.g. supported

by an information prescription)

Underpinning good services

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Section 3: Commissioning a world class long term conditions serviceThissectionillustratestheappropriateactionateachstageofthecommissioningcycletosecureaworldclassserviceforpeoplelivingwithlongtermconditions(LTCs).Ithighlightsasuggestedapproachintermsoftheactionscommissionersshouldconsiderwhenimplementingpersonalisedcareplanningandselfcaresupportstrategies.TheTopTipsinAnnexAaimtohelpcommissionersidentifywhatwillhelpthembecomeworldclassandsecureaservicethatwillfitwiththeneedsofpeoplelivingwithoneormoreLTCs.

AworldclassserviceforpeoplewithLTCswillensurethat,throughcareplanning,therecanbearealdialogueandshareddecisionmakingbetweenprofessionalsandpeoplewithLTCsaboutthefullrangeofchoicesavailabletosuittheperson’sneedsandlifestyle.Itwillfocusonwider,holisticneedstosupporthealthandwell-being,notjustamedicalmodelthatfocusesonlyontreatingillness.

CommissioningistheprocessbywhichPCTsandotherpublicsectorcommissionerssecurebestvalueanddeliverimprovementsinhealthandcareservices,tomeettheneedsofthepopulationstheyserve.WorldclasscommissioningisanationalprogrammethataimstodevelopworldclasscommissionersofNHS-fundedservices,leadingtoimprovedhealthoutcomesandreductioninhealthinequalities,addinglifetoyearsandyearstolife.Worldclasscommissionersconstantlysearchforwaystorefineandimprovewhattheydo,engagingwithpatients,public,othercommissioners,cliniciansandproviderstoworkouthowbesttodelivertheservicesthatmeetcurrenthealthneedsaswellasthechallengesofthefuture.

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The NHS Vision is, with social care and third sector partners, to deliver a health and care system that is fair, personalised, effective and safe. World class commissioning will be one of the most important vehicles for delivering this vision. It will have a direct impact on population health and will significantly reduce inequalities between the areas with the worst health and population as a whole.

Reference:World Class Commissioning: Vision(DepartmentofHealth,December2007)

Thecommissioningcycleillustratestheprocesscommissionerswillworkthroughtosecureservicesfortheirpopulation.Itprovidesaclearunderstandingofthestepscommissionerstakeduringanycommissioningtransaction.Yetitalsoclearlydemonstratesthatcommissioningisessentiallyatransformationalapproach,whichrequiresstrategicdecisionsonneeds,servicedesignandshapingthestructureofsupply.Italsooutlinestheneedfortransactionalmanagementthroughcontractingandprocurement,allofwhichislinkedtopatientneedsandoutcomes.

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Patient and public involvementPatient and

pub

lic in

volve

ment

Commissioning cycle

Review current service

provision

2

Decide priorities

3

Shape structure of supply

5

Manage demand and ensure appropriate

access to care

6

Clinical decision making

7

Managing performance

8

Assess needs

1

Design service

4

Strategic planning

Service redesignManag

ing

dem

and

and

man

aging performance

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Commissioning personalised care planning and self care supportThefollowingpointssuggesttheappropriateactionsateachstageofthecommissioningcycletosupportimplementationofpersonalisedcareplanningandselfcaresupport.ThiswillhelpsecureaworldclassserviceforpeoplelivingwithLTCs.

CommissioningaservicebasedupontheprinciplesofpersonalisationandsupportingselfcarewillhelpdriveimprovementsinservicequalityforpeoplewithLTCs.Thisinturnwillsupportthedeliveryoftheproductivityimprovementsneededtoreallydriveforwardthechangesthatneedtobeachievedinthecomingyears.ImprovingthequalityandproductivityofservicesforpeoplewithLTCswillalsomeantakingappropriateactiontode-commissionineffectivetreatmentsandreplacethemwithevidencebasedcarewhichminimisesunplannedandoftenunnecessaryhospitalcare.

1. Assess needs of long term conditions populationAim:Jointlywithsocialcarepartners,understandyourlocalLTCpopulationintermsof(i)diseaseprevalence,demographics,deprivationlevels,socio-economicmake-upandmortalityratesand(ii)servicesthatpeoplewithLTCswantbasedontheirfeedbackandviews.

Recommendedactions:• WorkwithlocalauthoritypartnerstoundertakeaJoint

StrategicNeedsAssessment(JSNA),makinguseofLocalStrategicPartnerships,JointCommissioningBoardsandLocalAreaAgreements.

• Usesystematicandprovenriskstratificationtoolsand/ortechniquessuchastheCombinedPredictiveModeltostratifyriskforthewholeLTCpopulation.

• Workwithproviderstodevelopafeedbacklooptogatherandaggregateinformationaboutchoicespeoplearemakingthroughpersonalisedcareplanning.Thisshouldalsoincludemonitoringservicesrequestedthatarecurrentlynotavailable.

• DevelopmechanismsforroutineandsystematicfeedbackfromLTCpatientgrouprepresentativessuchastheNationalAssociationforPatientParticipation(NAPP),

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LocalInvolvementNetworks(LINks)andPatientAdviceandLiaisonService(PALS)aboutservicespeoplewithLTCswant.

• Findoutifthereareservicesthatpeopledon’twantorinterventionsthatareineffective,forexamplethroughNICEguidelines,PROMSdataandfeedbackfrompatientrepresentativesgroupsandthethirdsector.

• DevelopLTC-specificpatientsurveysforfurtherfeedback.

• Gatherinformationfromchoicesmadethroughpersonalhealthbudgets.

• UsesocialmarketingtechniquestogatherinsightsintodriversofbehaviourforgroupsofpeoplewithLTCs,toenablemoresophisticatedtargetingofinterventionstodrivebehaviourchange.

• Inareasofferingpersonalhealthbudgets,commissionersneedtoconsidertheservicespeoplearebuying,whichmaybenon-traditionalservices.

• Toobtainabetterunderstandingofthedifferentneedsoflocalcommunities,workwithlocalpartnerstoproduceanEqIAtoinformthedevelopmentofLTCsstrategies.

Applying these actions when implementing personalised care planning will help demonstrate meeting World Class Commissioning Competency 3 – Engage with public and patients, and 5 – Manage knowledge and assess needs. Theessenceofcareplanningisabouttrulyengagingwithpeople,encouragingtheirinputandviewsabouttheircareandfindingoutwhatcanreallymakeadifferencetosupportthemtoachieveoptimalhealthandwell-being.Thismeansthat‘microlevel’engagementistakingplaceacrossthewholepopulationofpeoplewithLTCswhotakeuptheofferofcareplanning.Thiscouldbeconsideredoneofthemosteffectivewaystoengagewithpeoplewhosevoicewouldotherwisenotbeheard.

Applying these actions when implementing a self care support strategy will help demonstrate meeting World Class Commissioning Competency 3 – Engage with public and patients, and 5 – Manage knowledge and assess needs.LocalYour health, your wayinformationisonewayofestablishinglocalneedsandrequirementsthroughdatacollectionwhenimplementingtheCarePlanningprocess.

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2. Review current service provisionAim:FindouttherangeofservicesalreadyavailabletomeettheidentifiedneedsofthosewithLTCsandconsiderhowtheseservicesmatchtheidentifiedneeds.

Recommendedactions:• Useoutcomesandactivitydatatobenchmarkagainst

bestpracticeevidence,i.e.useactivitydataandpatientfeedbacktounderstandwhichservicesaretheleastpopularorthemostineffective.

• Identifygapsincurrentservices.• Considertheservicesavailabletosupportselfcare,

informationandeducation–istheresufficientchoiceandcapacity?

• Lookatwhetherthereareinnovativeservicesandinterventionsoranynewservicesthatareprovenorhavepotentialtobeeffective.

• Lookattheprovidermix–i.e.NHS,private,thirdsector,localauthority,education.

• Considerwhichservicesmayneedtobedecommissionedasaresultofcommissioningofanynewservices.

• Inareasofferingpersonalhealthbudgets,considerwhatservicesbudgetholdersbuy.

• Workwithproviderstodevelopafeedbacklooptogatherandaggregateinformationaboutchoicespeoplearemakingthroughpersonalisedcareplanning.Thisshouldalsoincludemonitoringservicesrequestedthatarecurrentlynotavailable.

Applying these actions when implementing personalised care planning will help demonstrate meeting World Class Commissioning Competency 2 – Work with community partners, 5 – Manage knowledge and assess needs, and 8 – Promote improvement and innovation. Developingfullyintegratedcareplanningpromotespartnershipworkingamonghealthandsocialcareproviders,localgovernment,andthethirdsectoratbothstrategicandindividuallevels.

Applying these actions when implementing a self care support strategy will help demonstrate meeting World Class Commissioning Competency 2 – Work with community partners, 5 – Manage knowledge and assess needs, and 8 – Promote improvement and innovation. ImplementingYour health, your waywillprovideopportunitiestoworkcloselywithpartnersfromlocalgovernment,healthcareprovidersandthirdsectororganisations.

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3. Decide prioritiesAim:GoodneedsassessmentwillhighlightatleastoneLTCthatwillbechosenasapriority.Manycommissionerswillalsomakeimprovedhealthandwell-beingfortheLTCpopulationapriority,andmaychoosetodothisbyofferingpersonalisedcareplanning.

Recommendedactions:• Identifypriorities,usingneedsassessment,

understandingoftheLTCpopulation,demographicsandprevalenceofconditions,e.g.lookatwhatyourequalityanddiversityimpactassessmenttellsyouaboutyourpopulationandtheirrelativeneed.

• Determineprioritiesagainstdifferentfinancialscenarios,whileconsideringtechnicalandallocativeefficiency[technical–isthisthebestthingtodoforLTC?;allocative–priorityofdoingthisversusotherprioritiessuchasurgentandemergencycare].

• Usedatafromriskpredictiontoolstoassesswheretoprioritiseandtargetearlyinterventions.

• Makebetteruseofanalyticalskills,reportsandanalysisoftheLTCpopulation,andinvestintheseareasifunder-resourced.

• Giveprioritytoearlyinterventions,servicestosupportselfcare,andinnovativeandprovennewinterventions.

• Ensureresourcesareintherightplacetosupportpersonalisedcareplanningandsupportforselfcare.

• Lookatevidence-basedinterventionsordevelopalocalevidencebaseifthereisnothingavailablenationally.

Applying these actions when implementing personalised care planning will help demonstrate meeting World Class Commissioning Competency 4 – Collaborate with clinicians, 5 – Manage knowledge and assess needs, and 8 – Promote improvement and innovation.Theessenceofcareplanningisabouttrulyengagingwithpeople,encouragingtheirinputandviewsabouttheircareandfindingoutwhatcanreallymakeadifferencetosupportthemtoachieveoptimalhealthandwell-being.Thismeansthat‘microlevel’engagementistakingplaceacrossthewholepopulationofpeoplewithLTCswhotakeuptheofferofcareplanning.Thiscouldbeconsideredoneofthemosteffectivewaystoengagewithpeoplewhosevoicewouldotherwisenotbeheard.

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Applying these actions when implementing a self care support strategy will help demonstrate meeting World Class Commissioning Competency 4 – Collaborate with clinicians, 5 – Manage knowledge and assess needs, and 8 – Promote improvement and innovation.WorkingwiththelocalcommunitywillhelpshapetheYour health, your wayinformationintoaproductthatwholeheartedlymeetstheirneeds.

4. Design serviceAim:Servicesaredesignedtomeetthewider,holisticneedsofpeoplewithLTCswithanemphasisonservicestosupportpeopletoselfcare.

Recommendedactions:• EnsurethatservicesaredesignedwithinputfromLTC

patientrepresentatives.

• Ensurethatofferingpersonalisedcareplanningandpersonalhealthbudgetsinareaswheretheseareavailablearepartofthecarepathway.

• Moveawayfromthetraditionallinear,inflexiblecarepathwaytowardstheYearofCareconceptofamenuofchoices.

• Developintegratedcarepathwayapproachestoservicedelivery.

• Incorporateservicestosupportselfcareandstructuredpatienteducationintolocalpathwaysasroutine.

• Ensurethataccesstogenericselfcareservices,suchasgenericskillstraining,ispartofservicedesign.

• Stimulateandsupportimprovementinproviderinnovation.

• Considerestablishedeffectivemodelsthatdriveintegratedworking,personalisation,quality,innovationandefficiency,suchasmanagedcarenetworksandvirtualwards.

• Establishinformationsharingprotocolsandconsensus,e.g.providersgettingconsentfromindividualstosharetheirinformationwithsocialcaredirectcaregivers.

• Developinformationsystemstosupportsystematicsharingofinformation.

• Workwithproviders,inparticularGPpractices,togatherrichinformationfromcareplans;ideallythisshouldrecordunmetneeds.

• PromotethebenefitsofinformationsharingtopeoplewithLTCsandthepublic,encouragingearlydeterminationofwhoshouldhaveaccesstoinformationaboutthem.

• Includepatientrepresentativesinservicedesign.

24

Applying these actions when implementing personalised care planning will help demonstrate meeting World Class Commissioning Competency 2 – Work with community partners, 3 – Engage with public and patients, 4 – Collaborate with clinicians, 6 – Prioritise investment, 7 – Stimulate the market, and 8 – Promote improvement and innovation.Allowingthepatientvoicetofeedintodecisionmakingthroughlocalisedimplementationofpersonalisedcareplanningwillresultinbetterqualityservicedrivenbytheneedsofthelocalpopulation.

Applying these actions when implementing a self care support strategy will help demonstrate meeting World Class Commissioning Competency 2 – Work with community partners, 3 – Engage with public and patients, 4 – Collaborate with clinicians, 6 – Prioritise investment, 7 – Stimulate the market, and 8 – Promote improvement and innovation.LocalisedYour health, your wayinformationwillresultinthedeliveryofqualitylocalservicesdrivenbytheneedsofthelocalpopulation.

5. Shape structure of supplyAim:ToensurethatthereareproviderswhoareabletoofferthebroadrangeofservicestomeetholisticneedsofpeoplewithLTCs,stimulatinginnovation.

Recommendedactions:• Proactivelyseekoutinnovationandcreateaculture

withintheorganisationthatpromotesinnovation.• Basedonneedsandprioritiesidentified,activelyseek

providersofservicesthatofferpotentiallydifferentservices.Thismaymeaninnovative,newapproachessuchasvirtualwards,exerciseonprescription,different,holisticapproachestosupportweightmanagementandaccesstopsychologicaltherapiessuchasCognitiveBehaviouralTherapy(CBT).TheDepartmentofHealthisissuingguidanceintheformofarevisedPCTsupportguide,whichoffersfurtherguidanceonhowtoprocurehealthcareservices,includingwaystoseekinnovation.

• AllocatetimeforthePCTBoardtospecificallyconsidernewandinnovativeoffersofservicesfromprovidersnewtothemarket.

• Stimulatethemarketforprovidersofselfcareservices.• Lookatworkforcedevelopmentplans.Assessthe

skillmixoftheworkforceandwhetheritmeetsthe

25

needsofmorepersonalisedcare,e.g.arethereenoughalliedhealthprofessionals(AHPs),specialistnursesorcommunitymatrons?Canmorestaffsuchashealthtrainersbecommissioned?

• FindoutwhatisofferedinotherPCTsandgatherevidenceofeffectiveness.Sharelearningoneffectiveinterventionsandgoodprovidersofservices.

• Improvelocalsharedprovideragreements.• Considerhowtousecontractswithserviceprovidersasa

mechanismfordeliveringpersonalisedservicesforpeoplewithLTCs.

Applying these actions when implementing personalised care planning will help demonstrate meeting World Class Commissioning Competency 1 – Locally lead the NHS, 6 – Prioritise investment, 7 – Stimulate the market, 8 – Promote improvement and innovation, 9 – Secure procurement skills, and 10 – Manage the local health system.Careplanningtailoredtoindividualneedisawayofestablishinglocalneedsandrequirementsthroughaggregateddatacollectionfromindividualcareplans.Italsohastheabilitytoprovidegranularinformationthatcanidentifyhealthinequalitiesandunmetneed.

Applying these actions when implementing a self care support strategy will help demonstrate meeting World Class Commissioning Competency 1 – Locally lead the NHS, 6 – Prioritise investment, 7 – Stimulate the market, 8 – Promote improvement and innovation, 9 – Secure procurement skills, and 10 – Manage the local health system.LocalYour health, your wayinformationisonewayofestablishinglocalneedsandrequirementsthroughdatacollectionwhenimplementingtheCarePlanningprocess.

6. Manage demand and ensure appropriate access to careAim:Withmorepersonalisedservices,peoplewithLTCsshouldexpectwiderchoicebutwithinaframeworkofclinicalcosteffectiveness.Thiswillrequirestrategiesfordemandmanagement.

Recommendedactions:• EnsurepeoplewithLTCsandthepublicareawareofthe

choicesavailable.• SetupaPCTdirectoryofservices,particularlyselfcare

andeducationprogrammes,forpeoplewithLTCs.ThisshouldbeindicativeifpeoplewithLTCs(through

26

personalhealthbudgets)wantsomethingthatisnoton‘thelist’.Itshouldbeconsideredonacase-by-casebasis.

• DevelopcommunicationslineswithpeoplewithLTCsandthepublicaboutwhattheycanandcannotexpectfrompersonalisationandchoice.

• ConsiderworkingwithotherPCTcommissioners(orpractice-basedcommissionerstopoolresourcestomeetidentifiedneeds.Wherethereisalowdemandandnoserviceavailable,thiscouldbebasedonthemodelforspecialistcommissioningofservices.

• MakeuseoffundingflexibilitiessetoutinPractice Based Commissioning – budget setting refinements and clarification of health funding, flexibilities, incentive schemes and governancetoencouragepractice-basedcommissionerstosetasidepartoftheirbudgettouseflexiblyin-yeartomeetvariationinlocaldemand,whichshouldbestimulatedbypersonalisedcareplanningandYour health, your way.

• EnsurespeoplewithLTCscaneasilynavigateservicesavailabletothem(e.g.thattheyareawareofthechoicesofprovider,settingandtreatment,andknowwhattodoif/whentheirconditionworsensoriftheyaredissatisfied).

Applying these actions when implementing personalised care planning will help demonstrate meeting World Class Commissioning Competency 1 – Locally lead the NHS, 3 – Engage with public and patients, 6 – Prioritise investment, 8 – Promote improvement and innovation, and 11 – Make sound financial investments.Personalisedcareplanningcanbeavehicletounderstandingwherelocalneedismostneededanddeterminewhereinvestmentprioritieslie.Itcanalsorevealservicesthatarelesspopular,whichcansupportdecommissioning.

Applying these actions when implementing a self care support strategy will help demonstrate meeting World Class Commissioning Competency 1 – Locally lead the NHS, 3 – Engage with public and patients, 6 – Prioritise investment, 8 – Promote improvement and innovation, and 11 – Make sound financial investments. LocalYour health, your wayinformationcanbeavehicletounderstandingwherelocalneedismostneededanddeterminewhereinvestmentprioritieslie.

7. Clinical decision makingAim:ToensurethatclinicalexpertiseisfullyutilisedbyfullyinvolvingcliniciansindecisionsaboutLTCservices.

27

Recommendedactions:• Takealeadershiproleinassessingneedanddesigning

andperformancemanagingservices.• Supportclinicianstoco-createserviceswithpeoplewith

LTCsandsupportselfcare.• Createandsupportanenvironmentofuser-centred

collaborationandleadershipacrossprofessions.• Disseminateuseroutcomeandexperienceinformationto

informprofessionaldecisionmaking.• Ensureclinicianshavebaselinedandbenchmarkeddata

andinformationaboutLTCmanagement.

Applying these tips when implementing personalised care planning will help demonstrate meeting World Class Commissioning Competency 4 – Collaborate with clinicians, and 5 – Manage knowledge and assess needs.WorkingwithawiderangeoflocalclinicianssuchasGPs,nurses,AHPsandspecialistconsultantstoimplementcareplanningandfeedinginformationfromcareplanningintocommissioningdecisionswillensurethatservicescommissionedaspartoftheprocessarebasedonlocalknowledgeandneed.

Applying these tips when implementing self care support strategy will help demonstrate meeting World Class Commissioning Competency 4 – Collaborate with clinicians, and 5 – Manage knowledge and assess needs.WorkingwithawiderangeoflocalcliniciansintheprocessofimplementinglocalYour health, your wayinformationwillensurethattheservicescommissionedaspartoftheprocessarebasedonlocalknowledgeandneed.

8. Managing performance (quality performance outcomes)Aim:Toensurethattherightmetricsareputinplaceincontractswithproviders.MeasuresshouldrelatespecificallytothenationalandlocalvisionforLTCs.

Recommendedactions:• Considerthenationalandlocalobjectiveswhensetting

measures.• Specifymeasuresofoutcomeandexperience–useshort

termproxieswheretrueoutcomemetricsarelacking.• Investincleaningupdataandmakingdatasuchas

HospitalEpisodeStatistics(HES)moretimely.

28

• Investinanalytical,programmingandITsupporttogathermeaningfuldataandpresentthisinusableformatsforcommissioners,seniormanagersandclinicians.

Applying these tips when implementing personalised care planning will help demonstrate meeting World Class Commissioning Competency 10 – Manage the local health system.Personalisedcareplanning,togetherwithYour health, your wayshouldstimulateprovisionofawiderrangeofservicesbyapluralityofproviderstomeetholisticneeds.Thisshoulddrivechoice,continuousimprovementandinnovationbystimulatingnewservicestogetherwithinformationtosupportdecommissioning.

Applying these tips when implementing a self care support strategy will help demonstrate meeting World Class Commissioning Competency 10 – Manage the local health system. Your health, your wayinformationallowspluralityofproviderstomeettheinformation,healthandcareneedslocally,whichwilldrivechoice,continuousimprovementandinnovation.

AnOutlineServiceSpecification(OSS)forpersonalisedcareplanninghasbeenco-designedbytheDepartmentofHealthandPrimaryCareContracting.ThepurposeoftheOSSistoassistcommissionerstoputinplaceappropriatearrangementstoensurepeoplewithlongtermconditionshaveinformedchoiceof,andaccessto,servicesthatbestenablethemtomanagetheircondition.TheOSSaimstohelpPCTstodeveloptheirlocalthinkingandapproach,andtoworkwithproviderstochangeexistingwaysofworking,ratherthancommissionadditionalservices.

ConclusionFactorssuchasanageingpopulationandthelifestylechoicesthatpeoplemakemeanthattheprevalenceofLTCswillcontinuetorise.Itisimperative,therefore,thatthereisafocusnowonimprovedLTCmanagement.Achievingthisshouldinvolvemoreproactive,preventive,plannedandpersonalisedservicesthatsupportpeopletobeindependentandincontroloftheirconditionandtohaveincreasedchoice.Personalisedcareplanningandsupportingpeopletodevelopconfidenceandcompetencetoselfcarecangoalongwaytowardsachievingtheseaims.

29

Tosupportcommissioners,thisdocumenthasillustratedwhat‘good’lookslikefromtheperspectiveofpeoplewithLTCs,theircarersandfamilies,professionalsandcommissioners.ItsetsoutthekeyareasforcommissionerstoconsiderwhencommissioningLTCserviceslocally.Ithasalsohighlightedasuggestedapproachintermsofactionstoconsiderwhenimplementingpersonalisedcareplanningandselfcaresupportstrategies.ConsideringtheseactionswillenablecommissionerstocommissionworldclassserviceswherepeoplewithLTCs,theircarersandfamiliesaregivenaccesstoconvenient,efficientservicesthatmeetindividualneedsandpreferences.

TheTopTipsinAnnexAhavebeendevelopedthroughinterviewswithpeoplewithLTCs,professionalsandmanagersfromhealthandsocialcareproviderorganisations,localauthorities,PCTsandpractice-basedcommissioninggroups.TheyaimtohelpcommissionersidentifywhatwillhelpthembecomeworldclassandsecureaservicethatwillfitwiththeneedsofpeoplelivingwithoneormoreLTCs,andprovidepracticalsuggestionstohelpnavigatethrougheachone.TheTopTipsoutlineanddrawconclusionsfromgoodpracticeseeninsomeselectedareasacrossthecountry.

TheTopTipsarespecificissuesthatcommissionershaveidentifiedwhentryingtocommissionservicesforpeoplewithLTCs.PracticalsuggestionsareprovidedtohelpnavigatethrougheachoftheTopTips.ThesehavebeendevelopedtosupportcommissionerswhentheyaredevelopingLTCscommissioningstrategies.

30

Annex A: Top Tips in detail, including examples of overcoming barriers to delivery

31

Proactively create a user-centred, can-do culture

Top Tips

1 • Create a simple, user-centred vision for the whole system.• Promote it using executive and professional champions/ role models, user stories, user-led training, etc.

One vision, strategy, priorities/targets shared by allcommissioners

2 • Invest in a close working relationship with other commissioners focused on a single vision.• Set joint strategy and priorities to meet the needs of all commissioners.• Set up clear joint working arrangements, whether or not commissioning teams are jointly appointed.

Stimulate and support provider innovation to improve care

• Encourage integration into teams of services not specific to any disease, e.g. community nursing, physiotherapy, occupational therapy, social care.• Support frontline co-working of integrated teams, e.g. team development, professional champions/role models, making populations coterminous.• Expose providers to ideas from elsewhere. • Fund pilots or use primary care trust (PCT) capacity and capabilities to support them.• Move away from care pathway to Year of Care ‘care packages’.• Seek to use individual budgets.

Assess risk using stratification techniques that will utilise hospital and primary care data, such as the Combined Model

4 • Specify use of the Combined Predictive Model plus professional judgement or, failing that, a simpler method, e.g. Whiteboard System. • Make simple assessments by telephone.

Use existing ways tosupport individuals withLTCs and carers to self care

• Support motivational interviewing and staff training.• Commission telephone health coaching for people with LTCs.• Commission disease or segment-specific courses, booklets/diaries and local information fairs.• Promote user support courses, engage GPs to refer and use sales and marketing techniques.• Use expert individuals and carers.• Consider investing in staff such as health trainers.

5

Develop the key outcomesand experience measures,which are relevant andmeaningful

6 • Provide a single specification and contract for jointly- commissioned services.• Specify integrated care and only a few of the most pertinent metrics.• Use shorter-term proxies where true outcome metrics are lacking.

Clear and professional responsibility for the well-being of specificindividuals

7 • Specify one key worker for each individual to co-ordinate and integrate across services and professionals.• Ensure those with the most complex needs have a key worker.

3Identify quick wins and small steps forward in IT (instead of trying to reach a big vision all in one go)

8 • Encourage remote read-only access.• Encourage transfer of paper records to one of the existing IT systems.• Support development/purchase of new IT for a workable subset of providers.

Establish informationsharing protocols and consensus

9 • Agree a local information sharing protocol.• Ask providers to get user consent to share information with the other local professionals who support them.• Encourage use of pseudo-anonymised reports to share. • Involve and engage professionals; make information sharing optional for GPs initially.• Promote information sharing protocols between health and social care professionals.

Engage and upskill primary and community care providers

10 • Bring GPs with you in all developments. • Create or specify roles responsible for improving a defined skill set in a defined provider set, e.g. practice staff’s ability to treat diabetes.

Using the Top Tips examples to overcome barriers to delivery

32 Source:Teamanalysis,expertinterviews

1 Proactively create a user-centred, can-do cultureAspectofgoodcommissioning:Ensureuser-centredcare

Roadblock to achieving this aspect of ‘good’ commissioning

How commissioners have overcome that roadblock

Examples

•Alackofauser-centredculture.

•Establishaclear,simple,‘sticky’visiontofocuseveryoneontheserviceuser

•Recruitexecutiveandprofessionalchampions

•Clearlycommunicate expectationsofworkforce.

Torbay•CommissionerandChiefExecutivebegantalkingaboutafictional85-year-old

requiringsupportfromdifferenthealthandsocialcareprofessionals,‘Mrs Smith’.ShewasadoptedbythefullPCTBoard,localauthorityChiefExecutive,andkeyprofessionalsandpoliticians–and,asaresult,bytheentirestaffbody.

Devon•Real-life people with LTCs and carer stories fromaroundthepatch,highlighting

theoutcomefortheuser,carerandstaff,arecommunicatedviawww.mylifemychoiceindevon.org.uk,innewsletters,teambuilding,presentations

•‘LearningtoInvolve’trainingforhealthandsocialcarestaffisdesigned and delivered by service users and carers(www.exetercvs.org.uk/projects/learning/learning-to-involve.php).

Central Bedfordshire•Usingimaginary people with LTCs(e.g.anoldmanandhisgranddaughter,with

descriptionoftheirsituation)torun‘whatwouldourservicesdonow’and‘whatshouldourservicesdo’scenariosfocusedonuseroutcomesandexperience.

www.exetercvs.org.uk/projects/learning/learning-to-involve.php

www.exetercvs.org.uk/projects/learning/learning-to-involve.php

http://www.mylifemychoiceindevon.org.uk

Source:Teamanalysis,expertinterviews 33


One vision, strategy and priorities shared by all commissioners

Aspectofgoodcommissioning:effectivejointworkingwithothercommissionersonLTCs

Roadblock to achieving this aspect of ‘good’


Examples

commissioning

•Co-workingnot •Establishaco-workingmindset: Devonalways supported by senior leadershipinthearea

–Ensuresenior commissioner leaders buy into and explicitly support joint working

•PCTandlocalauthorityhavedevelopedasinglejointhigh-levelstrategyforcommunity-basedhealthandsocialcarecalledTheWayAhead(www.devonpct.nhs.uk/)

•Businesscasesmake explicit the benefit to bothlocalauthorityandPCTs

•Commissionerleadersseeco-workingasfinancial burden,

–Uniteallpartnersaroundashared vision and strategy

–Findinitiatives which ‘tick every organisation’s boxes’,i.e.

•Asingle, joint commissioning teamappointedbylocalauthorityandPCTforMentalHealth,LearningDisabilities,OlderPeople,PhysicalDisabilitiesandsupportofcarersisjointlyaccountabletolocalauthorityDirectorofAdultSocialServicesandPCTDirectorofStrategicCommissioning

notasawayto targetsandstrategicpriorities, •RapidresponseinitiativepilotwasgovernedbytheUrgentCareBoard(includesjointly-overcomefinancial andmakebenefitstoeach appointedcommissioning,healthandsocialcareproviders,PBCandisjointlychairedbychallenges explicitinbusinesscases PCTDirectorofCommissioningandlocalauthorityDirectorofAdultSocialCare)

•Duplicated roles –Investinbuildingclose, •Gotsign-off for new models of service delivery(complexcareteams)at the highest acrosshealth trust-based relationships. level(CountyCouncilExecutiveCommittee,PCTBoard)beforerollingout.andsocialcare–difficulttogettheseworkingwelltogether.

Tower Hamlets•PCTandlocalauthoritywroteajoint primary and community care long term vision.

ThereisaworkinggrouponLTCswhichincludescommissionersfromboththelocalauthorityandPCT.ThisreportsintoanintegratedcareboardwithexecutivelevelrepresentativesfromthePCT,localauthorityandlocalacutetrust.

http://www.devonpct.nhs.uk/


2 One vision, strategy and priorities shared by all commissioners

34Source:Teamanalysis,expertinterviews

Aspectofgoodcommissioning:effectivejointworkingwithothercommissionersonLTCs



Examples

commissioning

•Governance •Supportwithsystemsand Derbyshirestructuresforjoint structures: •PCTandlocalauthorityconductjoint strategic planning,demonstratedinthelocal

areaagreement,jointcommissioningstrategiesforindividualserviceareas(e.g.olderpeople),andanagreementbetweenthePCTDirectorofCommissioningandlocalauthorityDirectorofAdultServicesontheprioritiesfortheyear

responsibilitiesunclear,insufficientorabsent

–Establishclear joint working arrangements includingdetailedplanningacrosscommissionerswithoversight •Joint LTC Commissioning Boardasasub-committeeofbothlocalauthorityandPCT

Boards•Lackofshared byexecutivesandboardsvision –Createone team with •Appointinga joint postforthesupportofcarers.

•Differentstrategic priorities.

jointresponsibilityforcommissioningLTCservicesacrosshealthandsocial

Torbay•Progressionofindividual budgetsforhealthcareallowscloserjointworkingofPCT

withlocalauthoritycare–whetherthroughjointappointmentsorco-location •Madeacleareconomic case for joint working based on objective returns on

investment for both organisations.–Pooledbudgetscanhelpbutarenotnecessarilythe Leedsanswer. •Leadersacrosshealthandsocialcaresigned off anintegratedcareapproach

•Leodispractice-basedcommissioning(PBC)groupisinvesting time to build relationshipswithsocialservicesfrontlinestaff,managers,executivesandpoliticians

•Integrated Care BoardreportstobothlocalauthorityandPCTBoards.


3 Stimulate and support provider innovation to improve care


Aspectofgoodcommissioning:Ensurethebestpossibleservicesareavailable



Examples

•Carepathwaysaretraditionallydesignedaroundone-offepisodesandspecificdiseases.

•Leavedisease-specific services in place andencourageintegration of non-disease-specific services(districtnursing,socialservices,occupationaltherapy,physiotherapyandpotentiallyalsomentalhealthandpharmacy)inintegrated,multidisciplinaryteamscentredonadefinedpopulation(ideallycoterminouswithGPpractices).

Torbay’sintegratedhealthandsocialcareZoneTeams:•One per GP practiceandresponsibleforthatlocalpopulation

•Includingspecialistsinmost-commonLTCs,nurses,socialworkers,occupationaltherapists,physiotherapistsandalayco-ordinatorwhoisthesinglepointofcontact

•Pooled budgets forusebythatteam

•Single assessment process

•One phone number forGPand/orserviceusertocall

•Co-ordinatoreitherdealswiththeproblem(e.g.equipment,domiciliarycare,mealsonwheels)orarrangescarefromtheappropriateprofessionalwithintheteam

•Teamcaninput remotely via the internet into the GP practice records.

Devon’sComplexCareTeams:•Oneortwoteamsineachof16‘clusters’,eachwithdesignatedGPpractices

•Includingsocialworkers,occupationaltherapists,physiotherapists,communityhealthworkers,communitymatronandolderpeople’smentalhealthworkersplusadministrativestaff

•Insomecasesincludesadomiciliarypharmacist

•Single assessment processtoidentifyindividualswithcomplexneedsandoneormoreLTCs

•Designedtomeettheneedsofolderpeople.

Derbyshire’s‘ShiresJoinedCare’:•Communitymatronandcaremanager part of a GP practice team

•Single assessment: eithercommunitymatronorcaremanager(oradelegate)assessesneedofahigh-riskindividualforbothhealthandsocialcare.







Examples

commissioning

•Differentfrontlineprofessionalsunusedtojointworking–andsometimesreluctanttotry.

•Supportand/orspecifythefollowingforintegratedteams:

TorbaysupportedthedevelopmentoftheZoneTeams:•Addressedestateschallengestoco-locatetheteams

–co-location •Communityandhome-basedteams aligned with GP practices

–team developmenttoclarifyjointgoalsforassignedpopulation,rolesandresponsibilitiesandjointworkingforbestuseroutcomesandexperience

•Developedteam chartersincludinggoals,rolesandresponsibilitiesandeachprofessional’suniquecontributionaswellasbeingpartoftheteam

•Arrangedjob shadowingbydifferentprofessionalstofosterunderstanding

•Resultedinstrong team working and a blurring of roles(a‘whileI’mthere’attitude)e.g.districtnursedoinghomecareneedsassessmentinsteadofafellowteammember.Wassimplifiedbythefactallteammembershavethesameemployer(theCareTrust)andemploymentterms–strongteam leadership

–information-sharingprotocolssothatfrontlinestaffcansharehigh-riskuserliststoeliminateduplicationandfindunidentifiedneed

•Startedwithuser-held‘yellowfolder’records;investinginsharedIT.

DevonsupportedthedevelopmentofitsComplexCareTeams:•Co-locatedteamsasmuchaspossible

•Oneortwoteamsineachof16‘clusters’,each with designated GP practices

•Targetsand/orfinancialincentivesnotalwaysnecessary

•Investedinongoing team building around integrated workingusingexternalfacilitation

•Usedreal-life user and carer storiestofocusteamsandmanagersontheserviceuser

•Ensuresupportforintegratedworkingfromkey professional leaders

•Evaluatedpilotintermsof10–12‘hardoutcomes’(e.g.admissionsavoided,numberofGPcontacts,etc.)aswellasuserexperience–toprovidefactbaseforintegratedworking

•Tryingtoblur roleswithintheteam•Influencetomakevarious

involvedproviderorganisationalunitscoterminous(e.g.aroundaGPpracticeorlocalpopulation).

•Fundeda resource dedicated to integratingthefrontline

•Investedinshared IT.

Derbyshire•CommunitymatronandcaremanagerpartofaGPpracticeteamandbased at the

practice.







Examples

commissioning

•Lackofhome-growninnovationamongproviders.

•Facilitateprovidersbeinginfluenced and inspired by ideas from other areas

Devon•VirtualWard(aspilotedinCroydon)anduseoftheCombinedPredictiveModelstarted

byGPafterattendingaKing’sFundpresentationaboutit

•Co-createideastogetherwithproviders,leadprofessionals,etc.

•Pilotedrapidresponseteaminoneareatotesteffectivenessandefficiency.

Derbyshire

•Pilotinnovationsinpartsofpatchtoproveconcept,evaluatesuccessanddecidewhethertoroll-out,refineordrop

•APBCgroupsetupaneffectiveanginamanagementprogrammeafterbeingfundedbyPBCtoattendapresentation by the Health Improvement Foundation,resultinginanecdotalsignificantimprovementinwell-beingofparticipants

•Castlefields joint care modeladaptedandpilotedinShires

•Commissionerbrought cardiac professionals to see successful rehab modelsinotherareas•UseaneagerPBCgroupasa

testbedfornewideas. •Commissionerco-developed several new service ideaswiththeproposingprofessional,e.g.HeartFailureHospitalatHome

•PBCgroupprovided project managerfor‘ShiresJoinedCare’teampilot

•Commissionerhosted meetingstodiscusspotentialimprovements,includingallrelevantprofessionals,resultinginsuchchangesaspalpitationsdirectaccessfromGPstoeventrecorders.







Examples

•Support pilot projectsbyfundingexpertise/projectmanagementand/orsupplyinganalyticalorothersupportfromthePCT.

Leeds•ForLeodisPBCgroupIntegratedCareforAdultsprogramme.PCThasseconded a

programme manager and supported using its own IT and analytical functions

•LeodisPBCgroupseesitselfasa‘lab in which to try new ideas’.

Tower Hamlets•SecondedPCTstafftoPBCgroupindevelopmentposts

•Commissionerfocuses improvement discussions on how to improve outcomes and experiencewithcurrentspendandallowsPBCgroup/providerstoretain any savings generatedaspartoftheimprovement.







Examples

commissioning

•Overly-prescriptiveservicespecificationscanstifleinnovation

•Specifyfew outcome and experience measures;supportproviderstodesigntheservicetodeliverthem

•[SeeTopTip6]

•Carepathwaysaddressconditions,notpeople

•Designandcommissioncare packages–holistic–notjustcomponentsofit

•DiabetesYearofCare(www.diabetes.nhs.uk/our_work_areas/year_of_care).

Torbay•Noindividual

budgetsforhealthcare.

•Findopportunitiestoindividualisecommissioningdecisions.

•ParticipatinginStaying in ControlandDepartmentofHealthIndividual Budgets pilot.Using‘service user trusts’toallowpeoplewithLTCs/carerstomanagetheirowncare,resultinginseveralindividualsbeingabletostayathomewhootherwisewouldneedtobeinhospital

•CareTrustfundingthreepersonalisation practitioners

•Excellence in Care trainingmademandatoryforCareTrustworkforcetopromotetherequiredculturalchange.

http://www.diabetes.nhs.uk/our_work_areas/year_of_care


4 Assess risk using stratification techniques that will utilise hospital and primary care data, such as the Combined Model


Aspectofgoodcommissioning:Ensureserviceusers’holisticneedsareidentifiedandaddressed



Examples

commissioning

•Processoralgorithmstosegmentusersbyrisklevelnotinplace

•Adoptavailablealgorithmstosegmentusersbyriskofadmission,makinguseofprimarycaredata

Devon•UsingKing’sFundCombined Predictive Modelalgorithm(www.networks.nhs.uk/177)

todetermineriskofadmission(trafficlightrating)–andapplyprofessionaljudgementtoupgradeordowngrade.

Tower Hamlets•Orexisting

algorithmsuseonlyretrospectivedata

•Professional algorithmincludingconsiderationofeyeorkidneyproblemsandrestrictedaccessusedforuserswithdiabetestodeterminesuitabilityforcommunitycare.

Derbyshire•Emergency Admission Risk Likelihood Index (EARLI) tool

(www.improvementfoundation.org)combinedwiththeCombinedPredictiveModel

•HeartFailureHospitalatHomeService:PeoplearrivinginhospitalProfessionalDecisionUnitwithheartfailurearejointlyassessed using a professional algorithm by a heart failure nurse and consultants for suitability for treatment in the communityratherthanadmission.

•Lesscomplexassessmentsarecompletedfacetoface,whichismoreresource-intensive.

•Completesimpleassessmentsandreferralsbytelephone.

Devon•‘MyDevon’isaDevon-widephone serviceforlocalauthorityservices,includingCare

Directforolderpeople,vulnerableadultsandtheircarers

•70%ofcallstoCareDirectrequireinformationandsignpostingandaredealt with in call;30%arereferredtoCareDirectPlus

•70%ofCareDirectPluscallersareassessed on the phone andinformation,adviceandserviceareprovidedthenandthereorarranged;theremaining30% are referred to complex care teamsforassessment.

http://www.networks.nhs.uk/177

http://www.improvementfoundation.org


5 Use existing ways to support individuals with LTCs and carers to self care


Aspectofgoodcommissioning:Maximiseselfcare



Examples

commissioning

•Lowtake-upofeducationcourses.

•EngageGPstoincreasereferrals Tower Hamlets•AsmallLocal Enhanced Service payment to GPs per attending patient.Diabetesproject

managergotlocalmedicalcouncilsupportandvisited every practicetodiscussselfcarecourseavailable.Thisresultedinalargeincreaseinnumberofnewly-diagnosedusersreferred,withsomeGPscallingduringaconsultationtofacilitatethepatientbookingontoacourse.

Derbyshire•CommissionersharedcomparativedataonGPreferraltousereducationcourses,

resultinginsignificantlyincreasedreferrals.

•Understandtheneedsandpreferencesoftheserviceuserpopulationanddesigna‘menuofservices’thatcatertothem.

Tower Hamlets•Researched needs and preferences of certain segmentsthroughresearchpublications

andtalkingtoprofessionals,communitygroupsandindividualswithLTCs

•53%ofpeoplewithdiabetesinTowerHamletsareBengaliand8%Somali,andcourses were tailored to reflect differencesinlanguage(Bengalicourses,investmentinSomaliLINksgroups),timepreferences(Bengaliserviceusersoftenwokeandsleptlater,makingmorningcoursesunsuitable),location(>40locations)andcultural sensitivities(e.g.women-onlycoursesandcourseswheremenandwomenwereseparatedbyascreen).

Birmingham•BirminghamOwnHealthprogrammeincludesEnglish,Punjabi,UrduandGujarati.







Examples

•IndividualswithanLTCaren’tmotivatedtoselfcarebecausetheyareaccustomedtopaternalisticcare.

•Motivationalinterviewandco-creationtrainingandculturalchangeforpracticestaff

•Motivationalcounselling/healthcoachingservice.

Barnsley and Derbyshire•Motivational interview trainingforprofessionalssothattheycanencourageusersto

selfcare.

Humana•‘PersonalNurse’providestelephone-based health coaching (informationandcare

navigation,motivationalcounselling,ongoingpersonalrelationship)toempowerindividualswithLTCsandsupportselfcare(www.humana.com/members/health/personal_nurse.asp).

Birmingham•BirminghamOwnHealthprogrammeprovidesproactivetelephone-based coachingto

residentswithLTCsinthemostdeprivedcommunities.CareManagerstakeaholistic,notjustdisease-based,approachtocareandaresupportedbybespokesoftwarethatisadaptedtoincorporatelocalguidelinesandpathways.Coversdiabetes,cardiovasculardisease,heartfailureandchronicobstructivepulmonarydisease(COPD)(www.pfizerhealthsolutions.co.uk/Pages/BirminghamOwnHealth.aspx).

East Surrey•CareCall–telephone-basedservicerunbyhealthcoacheswhoarehighly-trainednurses

withspecificskillstosupportpeopletostayhealthyandintheirownhomeforaslongaspossible,reducetheneedforhospitalstays,andhelpthemachievetheirownhealthgoals.Afterthreemonths,44%ofparticipantssaidtheyhadgreaterabilitytotalktotheirGPafterspeakingtoahealthcoachand94%ofthemsaidtheywouldrecommendtheservicetoafriend(www.mycarecall.net).

Health Foundation•Co-creating health programmeusesthreeenablers(agendasettingforpatient/

professionalinteractions,goalsettingandgoalfollow-up)

•Diabetes Year of Care(www.diabetes.nhs.uk/our_work_areas/year_of_care).

www.humana.com/members/health/personal_nurse.asp

www.humana.com/members/health/personal_nurse.asp

http://www.pfizerhealthsolutions.co.uk/Pages/BirminghamOwnHealth.aspx

http://www.mycarecall.net

http://www.diabetes.nhs.uk/our_work_areas/year_of_care



Examples

•Lowtake-upofeducationcourses.

•Usemarketingtechniquestoincreasetake-upandattendancerates.

Tower Hamlets•Usedmarketing team and technology to encourage referraltodiabetescoursesto

improveDNAratesfrom<50%to<5%.7,500peoplecompletedcoursesoversixmonths

•Used GP registers(inlinewithdataprotectionrules)towritetoeachpatientonbehalfofGPpractice,withmenuofavailablecoursesandadvisingtheywouldreceiveacall

•Phonecallwithinfiveworkingdaystoarrangeasuitable education course based on patient’s lifestyle, location and choiceandalsotoaddressanyquestionsorconcerns.Confirmationlettersenttwodayslater

•Promotionalstandsandeventsatlocalmarketscombinedwithmediaadvertising campaign to promote self-referral

•Coursetutorstextedorcalledparticipantsintherun-uptoeachsessiontoensure attendance.AllDNAswerefollowed-upbythecoursetutorand,ifnecessary,theprogrammeteam.Courseattendancewasactivelytrackedanddiscussedbytheteam

•Atcourses,staffencourageduserstoattendafollow-oncourseandmadeabooking and supplied a confirmation letter at course

•Programmehasdedicated project management resourceincludingdirectmarketingteamofsixfulltimeequivalentsandthreeadministrationstaff.











Examples

•‘Formal’educationprogrammesnotalwaysmosteffective

•Useexpert users

•Useoradaptdisease-oruser-segment-specificcourses or booklets

Derbyshire•Cardiacrehab‘buddy’ systemofvolunteerswhohaveexperiencedcoronaryheart

disease(CHD)whoadvisenewly-diagnosedusers,attendingconsultationshelpingthemtoabsorbinformation,andassistingtheminnavigatingtheircare

•COPD booklet,includingsymptom–remedy/actiondescriptionstoassistself-diagnosis,self-medicationandcontactnumbersforadvice,providersandout-of-hoursservices.

Barnsley•Self-care telephone serviceofcarenavigatorsforthoseselfcaring.

Devon•‘Gettingthemostoutoflife’isaweb- and paper-based information source for older

people,basedonthefieldsofinformationidentifiedasimportantforthewell-beingofolderpeopleintheSure Start to Later LifereportoftheSocialExclusionUnit,e.g.healthandhealthyliving,finance,housingandhome.Thereisanaccompanying‘360 degree well-being check’ tool which frontline staff have found very usefulinassessingolderpeople’sholisticinformation,aswellasservice,needs(www.devon.gov.uk/de/gtmool)

•Localinformation fairs for over-50s and their familiesverysuccessful.

Expert Patient Programme•Free six-week courseforpeoplewithLTCstohelpusersmanagetheircareand

symptoms(www.expertpatients.nhs.uk).

•Usershavelittlecontrolovertheirrecords

•Users can update their recordsandallowselectedprofessionalstoviewthem

Barnsley•Doc@homeenablesserviceuserstouploadtestresultsfromhomethroughahand-held

deviceandallowsselectedprofessionalstomonitortheirprogress(www.barnsley.nhs.uk/default.aspx.locid-02tnew00v.html).

•Carersunder-identified.

•EngageGPstoproactively‘case-find’carers.

Devon•ProgrammetoencourageandsupportidentificationbyGPsofcarershasbrought

significantnumbersofcarersintotheavailablesupports.

www.barnsley.nhs.uk/default.aspx.locid-02tnew00v.html

www.barnsley.nhs.uk/default.aspx.locid-02tnew00v.html

http://www.devon.gov.uk/de/gtmool

http://www.expertpatients.nhs.uk


6 Develop the key outcomes and experience measures, which are relevant and meaningful


Aspectofgoodcommissioning:Usecontractingtoensurethebestpossibleservicesareavailable



Examples

commissioning

•Absenceofajoint •Putinplaceasingle Devonlocalauthority–PCT specification and contractfor •Hastenderedsingle agency contracts.specificationandcontractprecludesjointperformance

jointly-commissionedservices Derbyshire•Writingasingle specificationforthestrokerehabserviceitwillsoonputouttotender.

managementofthe •Specifyonlya few of the most Derbyshireprovider pertinent metrics •Strokerehabspecificationwillincludenumberofphysiotherapyvisitsperweek,quality

•Degenerative oflifemetrics(stilltobeagreed)andmeasuresofserviceusersatisfactionnatureofsomeLTCsaredifficultto

•Anginamanagementprogrammemeasuresqualityoflife,drugsprescribed,numberofadmissionsandwhethersurgicalinterventionisultimatelyrequired.

capture •Specifythatservicemustbe Tower Hamlets•Differencesin providedby a multidisciplinary •Foritsdiabetescarepackage,commissionerisspecifyingactivitytypeandleveland

metricsbetween teamwhereappropriate deliverybyamultidisciplinaryteamaspartofanetwork.settingsofcare •Definethemodelofservice Devon

•Toomanymetrics delivery. •ComplexCareTeams’specificationswillinclude:makecontractunworkableandstifleinnovation.

–numberofemergencyadmissions(acuteorcommunity,includingwhetherhavesocialcareneeds)

–numberoflongtermcareadmissions

–lengthofstayanddelayeddischargesinacuteandlongtermcare

–numberofGPcontacts

–userexperiencesurvey

–timelinessofresponse.


6 Develop the key outcomes and experience measures, which are relevant and meaningful


Aspectofgoodcommissioning:Usecontractingtoensurethebestpossibleservicesareavailable



Examples

commissioning

–careprotocols,e.g.useofcase-findingtools,howneedwillbeassessed,sourceofinformationandhowitshouldberecorded,skillsrequiredintheteam,casemanagementmethod,empowermentofuserandcarer,admissionsavoidance,useofcomplementaryservices,existenceofkeystrategies(falls,stroke,etc.).

•Shortageof •Use shorter-term proxies for Various

trueoutcome longer-termoutcomes,e.g. •TimetoassessmentmetricsforLTCs–especially

processmetrics•Admissions

thosewhicharemeasurablewithin

•Lengthofstay.

afewyears

•Difficultto •Specify integration Tower Hamletsincentiviseactivitiesthatareimportantbutseenbyagivenprovideras

• Specify quality-of-life enhancing elementstotheservice

• Localauthorityretenderedforlunchclubstatingclearlytheywantedtheprovidertodomore than just a meal (but without specifying what).Thisresultedinseveralinnovativeservicesbeingaddedincludinglinedancing,ta’ichi,andsittingexercisesforthoseunabletostand

‘non-core’. •Specify case finding activities.• Specified case finding and self care promotionactivitiesfromitsprovidersofolder

people’ssocialservices

•LinkAgeprovidershouldgiveeachserviceuseracardtotaketotheoptometristtocompleteandreturntothemtotrytoaddressasignificantunidentifiedneedforeyehealthcareinthelocalolderpopulation

•Variousproviderstosignpostcare,checkhomefireandothersafetyandseektoidentifysociallyisolatedpeople.


7 Clear and professional responsibility for well-being of specific users


Aspectofgoodcommissioning:Encourageproviderinnovationtomaximiseuserwell-being



Examples

commissioning

•Lackofclear •GPis‘keyworker’forall Torbayprofessional peoplewithLTCsnotreferred •WithinintegratedhealthandsocialcareZoneTeams,a‘keyworker’isassignedtoeachresponsibilityfor toaCommunity Matronoran serviceuserbasedontheirdominant care need.thenavigationandintegrationofcareforindividuals

integratedcareteam

•Ifreferredtoanintegrated care team,ensurea‘keyworker’is

Devon•WithintheComplexCareTeams,thereisalwaysanassigned ‘case manager’foreach

serviceuser–themostsuitablememberoftheteam.appointedwithinthatteam(i.e.onepersonwhoco-ordinates Barnsleyandintegratesallservice •Telephonecarenavigators.provisiontoagivenindividual)

•Consideruseofdedicated care navigators

•Incentiviseprovidertoanalyse•Providersdon’t thepopulationtoidentifythe Devon

proactivelymanage needsandriskofdifferent •OneGPhasanLTCs nurse and an admissions avoidance nurse based at the practicetowell-beingoftheir groupswithinitandinnovate keeptheirpeoplewithLTCswellandavoidhospitaladmissions,fundedbyPBCgroupusers. toproactivelykeep users well

and out of hospital. •ComplexCareTeamsresponsible for the well-being and all needs of a defined high-risk segmentofthelocalpopulation.

Torbay•IntegratedhealthandsocialcareZoneTeamsresponsible for the needs of a defined

local population.


8 Identify quick wins and small steps forward in IT (instead of trying to reach a big vision all in one go)


Aspectofgoodcommissioning:Supportintegratedserviceprovision



Examples

commissioning

•ITdoesn’tsupportinformationsharing–allprovidersondifferentsystemsandgettingallonasingleITsystemisdifficult,lengthyandcostly.

•MaintainexistingITsystemsbutenableremoteaccess

Torbay•GivingacuteandGPpracticestaffread-only accessviatheinternettoasummaryof

socialcareITsystemserviceuserrecordsandgivingdistrictnursesremoteread-and-writeaccessviatheinternettoGPpracticerecords.

Tower Hamlets•Setting-upGP remote accesstoretinalscreeningserviceuserrecords.

•SupportthepurchaseofanewITsystemforselectedsetsofproviders

Torbay •ITsystemtogiveGPsremoteaccessviatheinternettosummariesofsocialcarerecords.

Tower Hamlets•RollingoutEMISWeb

–RolloutfirsttoGPsandcommunityteams

–Aimtorolloutinacute settings through disease-specific teamswithinsecondaryproviderstoavoidchallengesof100%roll-out.

•Make‘quick-win’stepstounifyingcareproviders’informatics.

Torbay•Moving previously paper-based records and selected electronic records ontooneofthe

pre-existing systems(districtnurse,occupationaltherapistandphysiotherapistrecordsontoexistingsocialcareITsystemPARR).

Tower Hamlets•UsingFACEassessmenttoolasasingle holistic assessment sharedacrosscase

management(socialservices)andcommunitymatron(healthservices)teams.


9 Establish information sharing protocols and consensus


Aspectofgoodcommissioning:Supportintegratedserviceprovision



Examples

commissioning

•Limitedinformation •Agreeinformation sharing Torbaysharing. protocol betweenlocal •Agreedinformation sharing protocolbeforebecominganIntegratedCareOrganisation

authorityandPCTandgetconsent to share information •Beinganintegrated organisationhasremovedmanyinformationsharingbarriers

from people with LTCsaspart •Awell-respectedPEC Chair has facilitated discussionsaroundinformationsharing.ofassessments

Leodis PBC group•InIntegratedCare

Organisations,frontlineproviderarmstaffhavethesameemployerwhich

•Investedtimetoreassure practices and partnersthatdatawouldbeanonymous.

Devon•Dedicatedresource and push to driveinformationsharing–resultedininformation

eliminatesblockstoinformation sharingprotocol.sharingbetweenthem. Tower Hamlets

•AninformaticsexpertGP chairs the committeeoverseeingthedraftingofprotocolsandproceduresforinformationsharinginprimarycare.


10 Engage and upskill primary and community care providers





Examples

•Providersdon’thavetherightskillstodeliverthebestpossibleservices.

•Appointrole(s)withresponsibilityforimprovingadefinedskillset.

Tower Hamlets•Diabetes consultant and team

–Roletoupskillprimarycareworkforceandreduce acute referrals

–AvailabletoGPpracticesforadvicebyvisits,phoneoremail.WillinformGPsonlatestdiabetescare,do‘rounds’ofcurrentdiabetescaseloadand see service users together with practice staff

–Consultantworks at acute trusttomaintainskillsandnetwork

–Issupported by Diabetes Centre specialist nurseswhoareassignedtoeightpracticeseachandproactivelyengagethem.Theyareperformancemanagedinthisregardbytheleadnurseandsupportedbyprofessionalpsychologist

–Thisteamhasreducedacutereferralsfrom20–30to6–7perweek

•GP networks

–Piloting‘networks’ of GPs,whosharespecialtiesandreferbetweeneachother,tocareformorecomplexusersinthecommunity.

Derbyshire•Specialist diabetes nursesupskillpracticesonbasicdiabetescare.

51

Annex B: Linked policies and initiatives with supporting information(Listed in alphabetical order)

Care Programme Approach (CPA)CPAwasintroducedin1990toprovideaframeworkforeffectivementalhealthservicesforpeoplewithseverementalhealthproblems.Itplacesanemphasisonpersonalisedcareplanning,ensuringthatindividualsandtheircarersareinvolvedindecisionsabouttheircare.Effectiveco-ordinationofserviceswithakeyworkertakingtheleadandamultidisciplinaryapproacharealsokeyelementsofCPA.Moreinformationcanbefoundat:www.dh.gov.uk/en/Publicationsandstatistics/Publications/DH_083650

Carers’ strategyThecarers’strategysetsouttheGovernment’sshorttermagendaandlongtermvisionforthefuturecareandsupportofcarers.Amoreintegratedandpersonalisedsupportserviceforcarerswillbeofferedthrougheasilyaccessibleinformation,targetedtrainingforkeyprofessionalstosupportcarersandpilotstoexaminehowtheNHScanbettersupportcarers.Thestrategycanbedownloadedat:www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_085345

Commissioning Framework for Health and Well-BeingThisframeworksetsouttheeightstepsthathealthandsocialcareshouldtakeinpartnershiptocommissionmoreeffectively.Itplacesanemphasisonpersonalisationofservices,puttingpeopleatthecentreofcommissioning.Theframeworkisaimedatcommissionersandprovidersofservicesinhealth,socialcareandlocalauthoritiesandispartoftheWhitePaperOur Health, Our Care, Our Sayimplementation.Theguidancecanbedownloadedat:www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_072604

Common Assessment Framework (CAF) for adultsTheWhitePaperOur Health, Our Care, Our Sayincludedacommitmenttodevelopacommonassessmentframework(CAF)foradultswhichwould:

1. improveoutcomesforadultsbyensuringapersonalisedandholisticassessmentofneed,focusedondeliveringindividualoutcomes;

2. supportimprovedjointworkingbetweenhealthandsocialservices;and

3. increaseefficiencythroughbetterinformationsharing.

www.dh.gov.uk/en/Publicationsandstatistics/Publications/DH_083650

www.dh.gov.uk/en/Publicationsandstatistics/Publications/DH_083650

www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_085345




52

TheCAFwillimprovethesharingofinformationaroundassessmentandcare/supportplanning.Itisagenericapproachtoassessingthehealth,socialcareandwidersupportneedsofindividualadultsandsupportingthiswithappropriateITsolutionsandpotentialfocusaroundConnectingforHealth.ItisanecessarypartofPutting People First’svisionforeverylocalityhavingasinglecommunity-basedsupportsystemfocusedonthehealthandwell-beingofthelocalpopulation.ThedevelopmentoftheCAFisexpectedtosupportpersonalisationandhelpunderpinthewideragendaoftheNHSNextStageReview,inparticularthroughsupportingdeliveryofanintegratedperson-centredapproachtoassessingpeople’sneedforsupportfromhealthandsocialcareservicesandthesupportneedsoftheircarers.Moreinformationcanbefoundat:www.cpa.org.uk/sap/caf_more_about.html

Common Core Principles for Self CareSkillsforHealthandSkillsforCarehaveworkedwithkeystakeholders,includingpeoplewhouseservicesandcarers,todevelopasetofcommoncoreprinciplestosupportselfcare.Theprinciplescapturebestpracticeinordertosupportservicereformandpromotechoice,control,independenceand

participationofthepeoplewhouseservices.Thisguidecanbedownloadedat:www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_084505

Confidentiality: NHS Code of PracticeTheCode’spurposeistoprovideguidancetotheNHSandNHS-relatedorganisationsonpatientinformationconfidentialityissues.TheCodeofPracticecanbedownloadedat:www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4069253

Dignity in CareTheDignityinCareCampaignaimstoeliminatetoleranceofindignityinhealthandsocialcareservicesthroughraisingawarenessandinspiringpeopletotakeaction.Moreinformationcanbefoundat:www.dh.gov.uk/en/SocialCare/Socialcarereform/Dignityincare/index.htm

End of Life CareInJuly2008theDepartmentofHealthpublishedanationalEndofLifeCareStrategyforadults,thiscountry’sfirst.Implementationofthestrategywilldeliverincreasedchoice

http://www.cpa.org.uk/sap/caf_more_about.html

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_084505


http://www.dh.gov.uk/en/SocialCare/Socialcarereform/Dignityincare/index.htm

53

toalladultpatients,regardlessoftheircondition,aboutwheretheyliveanddie.Itwillcoveradultpatientswithallconditions;caregiveninallsettings(home,hospital,carehomeandhospice);caregiveninthelastyear(s)oflife;andpatients,carersandfamilies.ItwillhelptotakeforwardthecommitmentsintheelectionmanifestoandintheWhitePaperOur Health, Our Care, Our Say.

Endoflifecareisalsooneoftheeightpathwaysthestrategichealthauthorities(SHAs)examinedtoproducethereportsthathelpedshapetheNHSNextStageReview.AsthestrategydevelopedweshareditsemergingfindingswithSHAstoinformtheReview,andinturnwetookaccountofthisimportantlocalworkinthedevelopmentofthefinalversionofthenationalstrategyitself.

Goodendoflifecareshouldattendtotheneedsofthewholepersonandthosewhoareimportanttothem.Peopleapproachingtheendoflifeshouldreasonablyexpectthattheircarewillbepre-plannedwhereverpossible;wellco-ordinated;equitable;andethicalwithregardtopreferencesandpersonalbeliefs.Involvingthepersonandtheircarerinplanningandagreeingacareplanand

identifyingtheirneedsandpreferencesforcareattheendoflifeensuresthattheyremainincontrol.Thisisfundamentaltoretainingaperson’sdignityatatimewhentheyarelikelytobefeelingattheirmostvulnerable.Endoflifecareisalsoanareawherethereisinputfromarangeofcareproviders,fromhealth,socialcareandthethirdsector,anditisequallyimportanttoensurethattheseservicesarewellco-ordinated.

TheseissuesarealladdressedintheEndofLifeCareStrategy.

Moreinformationcanbefoundat:www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_086277andat:www.endoflifecare.nhs.uk

Generic Choice Model for Long Term ConditionsThisgenericmodelhelpscommissionersunderstandtheprocessandrangeofservicesthatneedtobecommissionedtoimproveandpersonaliseservicesandsupportpeoplewithlongtermconditions(LTCs).Themodel,developedinconjunctionwithanumberofpatientorganisations,provides

http://www.endoflifecare.nhs.uk


54

goodpracticeexamplesandaimstoreduceinequalities.Themodelcanbedownloadedat:www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_081105

Health, Work and Well-beingHealth, Work and Well-being – Caring for our FutureisanambitiousstrategyputtogetherbytheDepartmentofHealth,theDepartmentforWorkandPensionsandtheHealthandSafetyExecutivetoimprovethehealthandwell-beingofworkingagepeople.ItplacesrealresponsibilitynotjustinthehandsofGovernment,butalsowithemployers,individuals,thehealthcareprofessionandstakeholders.Thestrategycanbedownloadedat:www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4121756

Improving Access to Psychological TherapiesThisinitiativeseekstodeliverontheGovernment’s2005GeneralElectionmanifestocommitmenttoprovideimprovedaccesstopsychologicaltherapiesforpeoplewhorequirethehelpofmentalhealthservices,andtoofferamorepersonalisedservicebasedaroundtheirindividualneeds.Thetoolkitcanbedownloadedat:


Improving Quality in Primary CareThisisapracticalguidetosupportPCTsascommissionersofprimarycare,inworkingwithlocalcliniciansandotherstakeholders–includingpatients–topromotecontinuousqualityandproductivityimprovementinprimarycareservices.Thisguidecanbedownloadedat:www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_106594

Improving Stroke Services: a guide for commissionersImproving Stroke Servicespromotesthebenefitsoftakinganintegratedapproachacrossthewholeofthestrokepatientjourneytoensurethatopportunitiesforimprovingcareandmakingmoreefficientuseofresourcesarerealised.Itworksthroughthecommissioningcycletosetouthoweachstagemaybeappliedtostroke.Atthecentreofthecycleistheroleofpatientsandthepublic,towhomcommissionersmustbeaccountablefortheircommissioningdecisions.Theguidancecanbefoundat:www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_063260












55

In ControlInControlisaboutchangingthesystemofsocialcare.Itisforeverybodywhowantstocontroltheirsupportbyensuringthattheyknowwhattheyareentitledto.Serviceuserscancontroltheirmoneythroughindividualbudgetsasmuchastheywantaspartoftheirselfdirectedsupport.Moreinformationcanbefoundat:www.in-control.org.uk/

Independence, Choice and Risk: a guide to best practice in supported decision makingThisbestpracticeguideisfortheuseofeveryoneinvolvedinsupportingadults(18andover)usinghealthandsocialcarewithinanysetting,whethercommunityorresidential,inthepublic,independentorthirdsectors.ThisincludesallNHSstaffworkinginmultidisciplinaryorjointteams.Theguidecanbedownloadedat:www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/dh_074773

Individual budgetsThesewillempowerpeopleneedingsocialcaresupporttotakecontrolandmakedecisionsaboutthecaretheyreceivebybringingtogetheranumberofdifferentfundingstreamsandofferingatransparentwayofallocatingresourcestoindividuals.

Knowingthelevelofresourcesattheirdisposalcanhelpindividualsplanandcontrolhowtheirsupportneedswillbemet.Moreinformationaboutindividualbudgetscanbefoundat:www.dhcarenetworks.org.uk/personalisation/index.cfm

Information prescriptionInformationprescriptionisdesignedtoguidepeopletorelevantandreliablesourcesofinformationtoallowthemtofeelmoreincontrolandbetterabletomanagetheirconditionandmaintaintheirindependence.Itwillbenationallyrecognisedasasourceofkeyinformationonservicesandcarethatwillbeseamlesslyandformallyintegratedintothecareprocess.Furtherinformationcanbefoundat:www.informationprescription.info/

Interim Evaluation of Partnerships for Older People Projects (POPPs)Atotalof29localauthority-ledpartnershipsincludinghealthandthirdsectorpartners(voluntary,communityandindependentorganisations)havebeenfundedbytheDepartmentofHealthtodeliverandevaluatelocal,innovativeschemesforolderpeople.TheInterimEvaluationReportpublishedinOctober2008revealsanumberofpositivemessages,includingPOPPpilotsiteshavingademonstrable

www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/dh_074773

www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/dh_074773

http://www.in-control.org.uk/

http://www.dhcarenetworks.org.uk/personalisation/index.cfm

http://www.informationprescription.info/

56

effectonreducingemergencybeddayscomparedtonon-POPPsitesandpatientsreportingimprovedqualityoflife.TheinterimreportconcludesthatPOPPcanleadtobetterinvestmentanddisinvestmentdecisions,fasterdevelopmentofjointcommissioninginvolvingvoluntaryandcommunitygroupsandmorelocalworkingtoidentifyneedsandinformcommissioning.TheOctober2008evaluationreportcanbefoundat:www.networks.csip.org.uk/_library/Evaluation_of_POPP_interim_report.pdf

Joint Strategic Needs AssessmentTheLocalGovernmentandPublicInvolvementinHealthAct2007requiresPCTsandlocalauthoritiestoproduceaJointStrategicNeedsAssessmentofthehealthandwell-beingofitslocalcommunity.TheguidanceforJointStrategicNeedsAssessmentprovidestoolsforlocalpartnersundertakingaJointStrategicNeedsAssessmentanddescribesthestagesoftheprocess,includingstakeholderinvolvement,engagingwithcommunitiesandrecommendationsontimingandlinkingwithotherstrategicplans.Theguidancecanbefoundat:www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_081097

National Service FrameworksNationalServiceFrameworks(NSFs)arelongtermstrategiesforimprovingspecificareasofcare.Theysetnationalstandards,identifykeyinterventionsandputinplaceagreedtimescalesforimplementation.Alistofallthestrategiesandinformationaboutthemcanbefoundat:www.dh.gov.uk/en/Healthcare/Medicinespharmacyandindustry/DH_4000165

Outline Service Specification: Personalised Care Planning for People with Long Term ConditionsTheOutlineServiceSpecificationhasbeendevelopedtoassistcommissionerstoputinplaceappropriatearrangementstoensurepeoplewithLTCshaveinformedchoiceof,andaccessto,servicesthatbestenablethemtomanagetheircondition.Thisspecificationcanbedownloadedat:www.pcc.nhs.uk/204

www.networks.csip.org.uk/_library/Evaluation_of_POPP_interim_report.pdf

www.networks.csip.org.uk/_library/Evaluation_of_POPP_interim_report.pdf



www.dh.gov.uk/en/Healthcare/Medicinespharmacyandindustry/DH_4000165



www.pcc.nhs.uk/204

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Person-centred Planning for Learning DisabilitiesThisisamethodofsupportingandworkingwithpeoplewhohavealearningdisability.Ithelpstoworkoutwhattheindividualwantsfromlife,howbesttoachieveit,thekindofsupportapersonwillneedandhowitwouldbebestgiven.Moreinformationcanbefoundat:www.publications.doh.gov.uk/learningdisabilities/planning.htm

Pharmacy White PaperThissetsouttheGovernment’svisionofthefuturerolepharmacistscanplayindeliveringworldclasspharmaceuticalservices.Thisincludespharmacistsactingascentreswithinthecommunitypromotingandsupportinghealthylivingandhealthylifestyle,providingadviceandsupportonselfcareandofferingnewservicestothosewithminorailmentsandLTCssuchasroutinemonitoring,vascularriskassessmentandsupportformakingbestuseoftheirmedicines.ThefulleditionoftheWhitePaperbedownloadedat:www.official-documents.gov.uk/document/cm73/7341/7341.asp

Putting People FirstAcrossgovernment,thesharedambitionistoputpeoplefirstthrougharadicalreformofpublicservices,enablingpeopletolivetheirownlivesastheywish,confidentthatservicesareofhighquality,aresafeandpromotetheirownindividualneedsforindependence,well-beinganddignity.

Thisministerialconcordatestablishesthecollaborationbetweencentralandlocalgovernment,thesector’sprofessionalleadership,providersandtheregulator.Itsetsoutthesharedaimsandvalueswhichwillguidethetransformationofadultsocialcare,andrecognisesthatthesectorwillworkacrossagendaswithusersandcarerstotransformpeople’sexperienceoflocalsupportandservices.Moreinformationcanbefoundat:www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_081118

www.publications.doh.gov.uk/learningdisabilities/planning.htm

www.publications.doh.gov.uk/learningdisabilities/planning.htm

http://www.official-documents.gov.uk/document/cm73/7341/7341.asp

www.official-documents.gov.uk/document/cm73/7341/7341.asp




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SeealsoCommissioning Personalisation, a Framework for Local Authority Commissioners at:http://networks.csip.org.uk/Personalisation/PersonalisationResources/Type/Resource/?cid=3241;andthePersonalisation Network – aplacewherepeopleinvolvedinchangingtheadultsocialcaresystemcangetguidanceandexamplesfromacrossthecountryat:www.dhcarenetworks.org.uk/personalisation/index.cfm

Raising the Profile of Long Term Conditions Care: A Compendium of InformationThisdocumentupdatesthefirstcompendiumofinformationonLTCs,publishedinMay2004.ItwillfurtherinformallthosewhoareinvolvedinbothcommissioningandprovidingcareandsupportservicesforpeoplewithLTCs.ItfocusesontheoutcomesthatpeoplewithLTCssaytheywantfromservicesanddescribeshowmoreeffectivemanagementofLTCsinanumberofareasisdeliveringhigh-quality,personalisedcare.Moreinformationcanbefoundat:www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_082069

Single Assessment ProcessTheSingleAssessmentProcess(SAP)wasdevelopedfollowingrecognitionthatmanyolderpeoplehaveawiderangeofhealthandsocialcareneeds,andthatagenciesneedtoworktogethertoensurethatassessmentandsubsequentcareplanningareeffectiveandco-ordinated.Careshouldbeholisticandinvolveserviceusers.MoreinformationaboutSAPcanbefoundat:www.dh.gov.uk/en/SocialCare/Chargingandassessment/SingleAssessmentProcess/index.htm

Summary Care RecordTheSummaryCareRecordispartoftheNHSCareRecordsServiceandisbeingimplementedaspartoftheNationalProgrammeforITintheNHS.Initiallyitwillcontainasmallbutimportantdatasetofcurrentmedication,allergiesandadversereactions,whichwillbeuploadedfromGPsystems.TheSummaryCareRecordwillbeavailablethroughoutEnglandtothosewhoneedtoaccessittodelivercareandwhohavethenecessarysecuritypermissions.Consequently,ithasthepotentialtobringmajorbenefitstobothpatientsandclinicians,especiallywhentreatmentisbeingdeliveredinsettingswherethepatient’susualrecordsarenot

http://networks.csip.org.uk/Personalisation/PersonalisationResources/Type/Resource/?cid=3241



www.dhcarenetworks.org.uk/personalisation/index.cfm

www.dhcarenetworks.org.uk/personalisation/index.cfm



www.dh.gov.uk/en/SocialCare/Chargingandassessment/SingleAssessmentProcess/index.htm

www.dh.gov.uk/en/SocialCare/Chargingandassessment/SingleAssessmentProcess/index.htm

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available.Moreinformationcanbefoundat:www.nhscarerecords.nhs.uk/

Supporting People with Long Term Conditions: Commissioning Personalised Care Planning – A guide for commissionersThisdocumentsetsouttoprovidecommissionersofhealthandsocialcareserviceswiththeinformationandsupporttheyneedinordertofulfiltheirobligationtoembedpersonalisedcareplanningintheirlocalities.Itdescribeswhatpersonalisedandintegratedcareplanningis,whatthebenefitsareandwhatthismeansforthemascommissioners.ItsupportsworldclasscommissioningandtheaimsofPutting People First: A shared vision and commitment to the transformation of adult social carewithafocusontrulypersonalisedservices,promotinghealthandwell-being,andensuringproactive,planned,co-ordinatedandintegratedservices.Thisdocumentcanbedownloadedat:www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_093354

Transforming Services for People with LTCsThisbestpracticeguidehasavitalroletoplayinthedeliveryoftheintentionsforHigh Quality Care for All: NHS Next Stage Review Final Report.Thisdocumentcanbedownloadedat:www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_101425

Whole System DemonstratorsTheWholeSystemDemonstratorsprogrammeisexploringtheexcitingpossibilitiesopenedupbytrulyintegratedhealthandsocialcareworking,supportedbytelehealthandtelecare.Thedemonstratorswillleadtoabetterunderstandingofthelevelofbenefitassociatedwithsuchinnovativedevelopments.Theevaluationconductedbytheprogrammeassessestheimpactoftelehealthandtelecareservicesonclinicaloutcomes,servicecosteffectiveness,individuals’andcarers’qualityoflifeandwell-being,andprofessionals’lives.ThedemonstratorsinCornwall,KentandNewhamwillalsohelptofast-trackfuturechangebyaddressingthekeyimplementationbarriersandprovidingsolutionsforthewiderNHSandsocialcareservices.






http://www.nhscarerecords.nhs.uk/

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Moreinformationaboutthisprogrammecanbefoundat:www.dh.gov.uk/en/Healthcare/Longtermconditions/wholesystemdemonstrators/index.htmand:www.wsdactionnetwork.org.uk/about_wsdan/index.html

World Class CommissioningWorldclasscommissioningwilltransformthewayhealthandcareservicesarecommissionedandwilldeliveramorestrategicandlongtermapproachtocommissioningservices,withaclearfocusondeliveringimprovedhealthoutcomes.Therearefourkeyelementstotheprogramme:avisionforworldclasscommissioning;asetofworldclasscommissioningcompetencies;anassurancesystem;andsupportanddevelopmentguidance.Moreinformationcanbefoundat:www.dh.gov.uk/en/Managingyourorganisation/Commissioning/Worldclasscommissioning/index.htm

World Class Commissioning Assurance Handbook Year 2ThishandbookprovidesadetailedexplanationandpracticalguidetoworldclasscommissioningassuranceYear2.Thehandbookcanbedownloadedat:www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_105117

Year of CareYearofCarehelpspeopletoexercisechoiceandbepartnersindecisionsabouttheirowncare,andsupportsthemtoselfcareeffectively.Itmakesroutineconsultationsbetweencliniciansandpeoplewithlongtermconditionstrulycollaborative,through care planning,andensuresthatthelocalservicespeopleneedandwanttosupportthisareidentifiedandmadeavailable,through commissioning.

Thefirstyearofthisthree-yearprojectusedpilotsasa‘testbed’fortheseideas.Thepilotshaveproducedadetailedcommissioningmodelforcareplanningindiabetes.Atrainingprogrammeforcareplanningisclosetocompletion.

Furtherinformationcanbefoundinthefollowingservices:

NationalDiabetesSupportTeam(2008)Partners in Care: A guide to implementing a care planning approach to diabetes care:www.diabetes.nhs.uk/document/php?0=75

www.dh.gov.uk/en/Healthcare/Longtermconditions/wholesystemdemonstrators/index.htm

www.dh.gov.uk/en/Healthcare/Longtermconditions/wholesystemdemonstrators/index.htm

www.wsdactionnetwork.org.uk/about_wsdan/index.html

www.wsdactionnetwork.org.uk/about_wsdan/index.html

www.dh.gov.uk/en/Managingyourorganisation/Commissioning/Worldclasscommissioning/index.htm






http://www.library.nhs.uk/DIABETES/ViewResource.aspx?resID=286967

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DiabetesUKGetting to Grips with the Year of Care: A practical Guide:www.diabetes.org.uk/upload/Professionals/Year%20of%20Care/Getting%20to%20Grips%20with%20the%20Year%20of%20Care%20A%20Practical%20Guide.pdf

YearofCareProgramme:www.diabetes.nhs.uk/our_work_areas/year_of_care

Your Health, Your Way (formerly the Patients’ Prospectus)Launchedon2November2008onNHSChoiceswebsite,Your health, your waywillprovidepeoplewithLTCswiththeinformationtheyneedaboutthechoiceswhichshouldbeavailabletothemlocallytoenablethemtoselfcareinpartnershipwithhealthandsocialcareprofessionals.FormoreinformationaboutYour health, your wayvisittheNHSchoiceswebsiteat:www.nhs.uk/yourhealth/Pages/Homepage.aspx

www.diabetes.org.uk/upload/Professionals/Year%20of%20Care/Getting%20to%20Grips%20with%20the%20Year%20of%20Care%20A%20Practical%20Guide.pdf




www.diabetes.nhs.uk/our_work_areas/year_of_care

www.diabetes.nhs.uk/our_work_areas/year_of_care

www.nhs.uk/yourhealth/Pages/Homepage.aspx

www.nhs.uk/yourhealth/Pages/Homepage.aspx

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Annex C: Glossary

Care planAsingleoverarchingplanthatrecordstheoutcomeofdiscussionbetweentheindividualbeingcaredforandtheprofessionalresponsible.Itmaybeelectronicallystoredorwrittenonpaper.Itshouldbeaccessiblebytheindividualinwhateverformissuitableforthem.

CarerAnindividualwhoprovidesorintendstoprovidepracticalandlongtermemotionalsupporttosomeonewithalongtermcondition.Theymayormaynotlivewiththepersoncaredfor.Carersmayberelatives,partners,friendsorneighbours.Theymaybeyoungpeoplewhofindthemselvesinthepositionofneedingtosupportanunwellperson.Apersonmayhavemorethanonecarer.

CommissioningThemeanstosecurethebestcareandthebestvalueforlocalpeople.Itistheprocessoftranslatingaspirationsandneeds,throughthespecifyingandprocuringofservicesforthelocalpopulation,intoserviceswhich:• deliverthebestpossiblehealthandwell-being

outcomes,includingpromotingequality

• providethebestpossiblehealthandsocialcareprovision• achievethiswithinthebestuseofavailableresources.

ComplexAtermusedtodescribepatientsthathaveanintricatemixofhealthandsocialcareneeds.Becauseoftheirvulnerability,simpleproblemscanmaketheirconditiondeterioraterapidly,puttingthemathighriskofunplannedhospitaladmissionsorlongterminstitutionalisation.

HolisticInmedicaltermsdenotesatreatmentorservicewhichdealswiththeneedsofthewholeperson,notjusttheinjuryordisease.

Long term conditionAconditionthatcannotatpresentbecured,butcanbecontrolledbymedicationandothertherapies.

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Multidisciplinary teamAteammadeupofprofessionalsacrosshealth,socialcareandthethirdsectorwhoworktogethertoaddresstheholisticneedsoftheirpatients/clientssoastoimprovedeliveryofcareandreducefragmentation.

Patient-centredDenotesanorganisation’sprovisiontosupportpersonalisedcaredelivery.

Personalised Describescareandservicesthatareindividualisedandtailoredtothepersonreceivingthem.

Self care/self managementTheprincipleofindividualsbeingsupportedtotakeresponsibilityfortheirownhealthandwell-being.Thisincludesstayingfitandhealthy,bothphysicallyandmentally;takingactiontopreventillnessandaccidents;thebetteruseofmedicines;treatmentofminorailments;andbettercareoflongtermconditions.

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