the year of care programme: evidence and experience

A partnership programme being delivered by the Department of Health, Diabetes UK, The Health Foundation and the National Diabetes Support Team

The Year of Care programme: Evidence and

experience

The Nuffield Trust & NHS Confederation10 September 2009

1. Dr Sue Roberts(Chair of the Year of Care Programme Board)

2. Avril Surridge (Representative User)3. Dr Douglas Russell (Medical Director,

NHS Tower Hamlets)

PANEL

This morning• The headlines

– Why year of care– What is it? ........and what it is not!– Learning so far

Discussion

• The components– Care planning … and the challenges

Discussion

– Commissioning ….and the challengesDiscussion

• The next steps / round up

The aspiration

• NHS National Plan:2000Step by step over the next ten years the NHS must be redesigned to be patient centred –to offer a personalised service.

– …. by 2010 it will be common place.

The aspirationThe Wanless Report 2002

• The Fully engaged scenario

• Every £100 spent on self care saves £150

The aspiration

“Over the next two years, every one of the 15 million people with one or more long-term conditions should be offered a personalised care plan”

The realityIs the NHS becoming more patient centred?Picker- September 2007

had at least one check up in the last 12 months

anddiscussed ideas about the best way to manage their diabetes

agreed a plan to manage their condition over the next 12 months

discussed their goals in caring for their diabetes

The reality: Diabetes

From ‘Managing Diabetes’ Healthcare Commission: 2007

Doing something different?

From ‘Managing Diabetes’ Healthcare Commission: 2007

addressing the gap?

Year of Care – addressing the gap

•A laboratory….

using the mechanisms of health reform to embed personalised care and support in routine practice for people with Long Term Conditions – developing generic principles from diabetes

The big lessons• Highly motivational for all

• No one finding it easy!– Not just an add on– Major cultural / philosophical change: for all– Complex intervention

• All components must be present together to achieve outcomes– Systems thinking : commissioner levers /work streams aligned.

• Organisational will – right from the top, right from the start

• Clinical (primary care) champions essential

Today…

• We want to discuss the challenges…….as well as share successes

Quote from a GP• ‘This is absolutely 100% better for me and

my patients’

What is Year of Care ?

•The Year of Care project describes two components:

•It is firstly about making routine consultations between clinicians and people with long-term conditions truly collaborative, through care-planning,

•and then about ensuring that the local services people need to support this are identified and available, through commissioning.

MENU OF OPTIONSExamples

• Education

• Weight management

• Screening for complications

• Telephone review/support

• Smoking cessation advice

• Local authority exercise programme

• Specific problem solving

• EPP

• Buddying / walking groups…

Individual patient choices via the care planning process = micro-level

commissioning

Macro-level commissioning by the commissioner (PCT/practice) on behalf of the whole diabetes population

The key role of care planning in linking clinical care and commissioning

‘An end in itself’ ‘A means to an end’

NORTH OF TYNE

TOWER HAMLETS

CALDERDALE & KIRKLEES

• 39 practices

• 3 PCOs

• Rural and urban communities

• 8 practices

• Diverse communities

• High and low levels of deprivation

• 6 practices

• Primary and Secondary Care

• Significant health inequality

The Year of Care aims: How to….

• Establish care planning in routine use• Identify sections of the local population by

potential need for services• Develop new and existing providers to support

self management• Systematically link individual choices / service

use into population level commissioning• Identify costs, currently and within a Year of Care• Understand the implications for policy / NHS

reform

Evaluation• External evaluation: Mixed methods

– Data on• Quality of consultation• Experience and satisfaction• Health status / clinical measures• Services ability to support self management• Integration with commissioning • Costs

• Ongoing learning – by doing and sharing

• Wider debate

The key models Firstly care planning ….

Commissioning- The foundation

The care planning

consultation

Commissioning- The foundationCommissioning- The foundation

The care planning

consultation

…and then commissioning

The ‘House’The ‘Windmill’

Learning and sharing: the biggest issue

Getting the ‘language right!’

Common confusions

• Care planning vs. Year of Care?

• Care plans or care planning?

• Year of Care = ‘closer to home’, better access, ‘integrated care’, predictive modelling, service redesign?

Need common understandingof…

• “Patient centred”

• “Support for self management”

• “Components of a diabetes service”

Care plans vs. care planning

• 2004 National LTC target

• Reduction in emergency beds days via care coordination and care plans

• Community matrons

Care plans and care planning:A continuum

•Frail and symptomatic

•Aim: Care coordination

•Service main ‘actor’

•Care plan critical

‘it’s the noun!’

2004 national target

•Often asymptomatic

•Aim: prevention of deterioration

•Support for self management

•Individual is main ‘actor’

•Care planning critical

‘it’s the verb!’

Year of Care

Self care / self management•Living with diabetes

•Lifestyle issues

•Community support

•Social capital

Traditional biomedical care.

•QoF / checklists

•Complex care

•‘doing to’

Commissioning headings for Long Term Conditions

= the ‘financial envelope’/ programme budget

Individual

needs

Year of Care

Consultation 1:1•Care planning / goal setting

•Joint decision making

•Collaboration

•‘doing with’

Challenge• Long term conditions are different: No fixes.

• Fundamental change needs multiple elements all aligned…….and sustained.

• How can such a strategic approach be supported?– Traditional solution is to break complexity into parts.– When no common language and poor understanding.– When financial pressures dictate tactical ‘cuts’.

Patient focussed care planning

Avril Surridge

The patient’s viewpoint….an informed patient who wants to be in control

of my own care.

……the best person to be in control of my care.

I know ME better than anybody else!

…..I live with diabetes all day and every day of my life.

Patient focussed?

• Patient at the centre.

• Planning care around the needs and wants of the individual patient.

Why?

• Patient focussed care planning involves a meaningful and productive partnership between patient and HCP which will improve outcomes clinically, socially, psychologically and ultimately financially at the same time as improving quality of life.

• We can’t therefore afford to ignore it!

Long term condition marathon

• Longer than 26 miles.• No finishing line. • Distance markers (the goals).• Increased knowledge, technology

developments, personal experience, clinical indicators and lifestyle improvements.

• More difficult for the patient than the HCP!

Actively participating patients

• Take ownership of the goals and actions and are therefore much more likely to adhere to them since they are part of the decision making process.

• Effective change doesn’t happen if those who need to change are not involved.

Changes needed

• HCPs must recognise the patient is in charge of outcomes.

• Telling us what to do doesn’t work!• Support, guidance and resources. • Goals have to be owned by me to be

achievable. • Task of the HCP to motivate me and

provide me with the tools.

Agreed & shared care plan

Information gathering

Goal setting and action planning

Information sharing

And discussion

Care Planning

Engaged,

informed patient

HC

P com

mitted to

partnership working

Organisational processes


The care planning consultation

Engaged,

informed patient

Engaged,

informed patient

HC

P com

mitted to

partnership working

HC

P com

mitted to

partnership working



Commissioning- The foundationCommissioning- The foundation



Engaged,inform

ed patient

HC

P comm

itted to partnership w

orking



Collaborativecare

planning consultation

Send test results beforehand

Contact numbers and safety netting

Consultation skills / attitudes

Senior buy-in & local champions to support & role

model

Integrated, multi-disciplinary team & expertise

Information/Structured education

‘Prepared’ for consultation

Emotional & psychological

support

IT: clinical record of care planning

The first practical step?

…………it makes a difference

• Sending out test results 1-2 weeks before the care planning consultation.

• A core component of care planning.

Qualitative study

PatientsI could focus on the important things for

me and get help

Time to read [results] and think about what to raise… you know

what was coming

Took the ‘cork out of the bottle’

I enjoy doing the clinic a lot more now… working with them rather than at them

It’s absolutely 100% better for me and for

the patients

People feel more

relaxed

and professionals

Engaged,inform

ed patient

HC

P comm

itted to partnership w

orking



Collaborativecare

planning consultation

Quality assure and measure

Procured time for consultations, training, & IT

Identify and fulfil needs

Summer 2009: A complete packageMaking it easier to do the right thing!

• An evidence base

• A tested clinical model

• An organisational framework

• Matching IT templates

• Quality assured training package– With training the trainers module

• Metrics and indicators– Being completed

So why is it difficult?

Challenges from healthcare professionals… maybe you too?

We do it already!

My patients don’t want it

Will it work?

What if they don’t do what

I think they should do?

Challenges from Commissioners….maybe you too?

I want to see in year savings

I don’t have time to do all this for one condition

This isn’t all in our

priorities with SHA

This will make

inequalities worse

Session overview

1. Micro to macro 2. A whole systems approach3. Developing new and existing provider to

support self management, 4. Identifying costs

Dr Douglas Russell

Improving diabetes care in Tower Hamlets is a top priority

CSP goal for diabetes

Diabetes in TH – key facts

Source: THPCT, NHSL, Vital Signs guidance, QOF – Information Centre for Health and social Care, YHPHO

• Our goal is to ensure 69% of all patients on the diabetes register have HbA1c < 7.5% (i.e. blood sugar controlled) by 2013

• The evidence suggests that controlling lifestyle factors has a significant impact on diabetes-related complications and mortality

• However it is not entirely clear that HbA1c is the best indicator of control…

• Diabetes register ~ 11,000 in TH • 1,700 – 2,200 undiagnosed• Prevalence expected to rise 1%

per year for the next 10 years• 53% of diabetics are Bangladeshi• TH population is 15% more likely to

have diabetes

12.013.616.016.0

London EnglandTHINEL

Diabetes attributable deaths (% of all deaths, 20-79 year olds), 2005 data

Rank 2 27 150/3 /29 /152

-

Variation across practices is significant and exception reporting

is high

Source: THPCT, NHSL, DH

2008/09 Q4 HbA1c<7.5 with and without exceptions

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0%

ST KATHARINE'S DOCK PRACTICESTROUDLEY WALK PRACTICE

ISLAND HEALTHLIMEHOUSE PRACTICE

SHAH KPTREDEGAR PRACTICE

DOCKLANDS MEDICAL CENTREWAPPING GROUP PRACTICE

AMIN NB POLLARD ROW PRACTICE

STROUTS PLACE MEDICAL CENTREBETHNAL GREEN HEALTH CENTRE

TOWER MEDICAL CENTREGLOBE TOWN SURGERY

MISSION PRACTICESPITALFIELDS PRACTICE

RANA AKBARKANTINE PRACTICE, THE

ST STEPHEN'S HEALTH CENTREHARLEY GROVE MEDICAL CENTRE

Tow er hamletsXX PLACE

BLITHEHALE MEDICAL CENTRE, THEALL SAINTS PRACTICE, THE

NISCHAL VK JUBILEE STREET PRACTICEISLAND MEDICAL CENTRE

ABERFELDY PRACTICESELVAN N

STEPNEY GREEN MEDICALALBION HEALTH CENTRE

EAST ONE HEALTHST PAULS WAY PRACTICE

VARMA, CMWHITECHAPEL HEALTH

Q4 without ExceptionsQ4 with Exceptions

SOURCE: Diabetes care package group; EMIS web data

We stratified patients based on clinical criteria…

Criteria for newly diagnosed

Newly diagnosed in the first 6 months or newly diagnosed in second 6 months not controlled

Currently 8% of patients

1

Off-target

Clinical parameters that exceed any or all of:

BP>140/80

HBA1C >7.5

Cholesterol >4.5


3Criteria for controlled

>6 months diagnosed and all three conditions met

BP<=140/80

HBA1C<=7.5

Cholesterol <=4.5 mmol


2

Complex off-target

Off target and

Renal, Limb, & Eye

Depression


4

Off-target

Controlled

TH is addressing the challenge through several initiatives

1) Education Programme (Jan-May 2009)

2) Care planning being implemented in all practices

3) Old LES updates to reflect care package components

4) Care packages in waves (Wave 1 –Sept, Wave 2 – Jan, Wave 3 – April)

1

2

3

4

Best practice education programme

TH needed better diabetes education

Uptake of education previously poor

Education for people with diabetes is established in the literature as a high impact intervention, but programmes at TH suffered from

• Low referral rate• Poor uptake and completion rate• High attrition rate• No choice • High cost

Did not attend

Attended education

86%

14%

Other reasons

Never offered

16%

84%

% responses to Health Care Commission survey*

SOURCE: Healthcare Commission survey, 2006, THPCT

Aims:• Reach 70% of the known 11,140

diabetes in TH• Raise patient awareness• Increase referrals by health

professionals• Offer tailored programmesInterventions:• 2 hour Key message Course• HAMLET structured course 4 x 3 hour

sessions• Healthy Moves exercise and cookery

classes• DVD and work book in 3 languages• Drop in sessionsOutcomes:• 9,940 total attendances• 100% received a DVD and workbook• Events held at 52 venues,7 days per

week in 18 languages

Education programme - £1.3m investment

The care package was developed to address the problems we faced with the previous LES

Old LES Care package

• Diabetes outcomes in Tower Hamlets are among the worst in the country due to the demographic characteristics of our population

• The previous LES did not provide a means of incentivising practices to collaborate

• Good practice was not shared systematically and this generated inequality

• Creates processes to ensure peer support and challenge

• Attaches financial incentives to agreed minimum standards

• Dashboard ensures incentives are tied to the right outcomes

• Provides a more robust performance management system than the LES

• Data sharing to improve management processes

No. with BMI >30

100

No. with >5% weight loss

12

Wt loss intervention

30

Wanted to lose weight

50

Issue: Goals: Action: Outcome:

Gap:20

A: 10B: 10C: 10

642

Linking Micro- to Macro-commissioning

Customised IT support

The Commissioning Windmill

Care planning and clinical care

Specific tailored information to support care planning

Needs assessment

User involvement

Local involvement

Focus groups for carers

North Tyneside

User GroupCalderdale &

Kirklees Diabetes UK

voluntary group

Tower Hamlets patient events

Engaging in the wider

communityLocal

people and groups

People with diabetes on

project boards

Provider Development

Summary of local engagement

Our biggest challenge:• Establish care planning in routine use• Identify sections of the local population by

potential need for services• Develop new and existing providers to support

self management• Systematically link individual choices / service

use into population level commissioning• Identify costs, currently and within a Year of Care• Understand the implications for policy / NHS

reform

National PCT scores against WCC competencies

Work with community partners

Stimulate the market

Prioritise investment

Collaborate with clinicians

Engage with public and patients

Manage the local health system

Promote improvement and innovation

Secure procurement skills

Manage knowledge and assess needs

Locally lead the NHS1

2

3

4

5

6

7

8

9

10

S

T

R

O

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G

E

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W

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A

K

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Provider development survey results

• No Provider Development Manager in PCTs• No incentives for providers to enter the market• No change management support• Few non-NHS services• No work to develop community providers- ‘public health does that !’

‘I’m not sure PCTs know what to do’

Finally … what about costs?

• Detailed information on individual spend on services and care before and after a Year of care approach

• Client Services Receipt Inventory (CSRI)

• Hope to have first data to the Department of Health this autumn.

Over to you.

the year of care programme: evidence and experience

Health & Medicine