www.england.nhs.uk

What

matters

most?

Jacquie White

Deputy Director - Long Term

Conditions, Older People and

End of Life Care

Clinical Policy & Strategy Team

NHS England

LTC Conference

27th October 2015

www.england.nhs.uk

Opening thought

The good physician treats

the disease; the great

physician treats the patient

who has the disease.

William Osler - 1800s

2

www.england.nhs.uk

The journey in England so far

National initiatives

(pre 2012)

Health & Social

Care Act (2012)

National Collaboration for integrated care (2013)

Person centred

co-ordinated

care framework

(2013)

Five year forward

view 5YFV (2014)

?

Integration pilots,

Community Matrons, Self management, Technology, PHB, Year of Care budgets

“Duty”, New organisations,

roles and responsibilites

– Local, National

National support –Narrative, definition,

Better care fund,

Integration pioneers

Permissive framework for

local implementation

Clarity of vision, priorities, new

national enablers: “new models of care”,

“integrated personal

commissioning”

?

3

www.england.nhs.uk 4

What matters?

Taxpayer

Government

Commissioners

Local Population

Providers

Practitioners

People with LTCs

www.england.nhs.uk

Follow the money –

understand the scale

13/11/

2015

Primary

£200

(6.5k)

Community & MH

£500

Specialist

£300

Acute

£1000

(330k)

Social Care

Public Health

• Difficulty defining R-point – can be a medical, community/social

or patient reason for delay after R-point determined

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

Aw

aiti

ng

Co

mm

un

ity

Bed

No

t m

edic

ally

fit

fo

rd

isch

agre

Aw

aiti

ng

OT/

PT

Ass

essm

ent

BLA

NK

For

furt

her

dia

gno

stic

s

Aw

aiti

ng

PT/

Men

tal

Hea

lth

/ So

cial

Car

e…

Aw

aiti

ng

soci

al c

are

asse

ssm

ent

Un

kno

wn

Aw

aiti

ng

OT/

PT

Aw

aiti

ng

OT/

PT/

Soci

al C

are

Pac

kage

Aw

aitn

g M

enta

lH

ealt

h A

sses

smen

t

Nu

rsin

g h

om

eas

sess

men

t

Aw

aiti

ng

soci

al c

are

pac

kage

Aw

aiti

ng

care

ho

me

to a

ccep

t b

ack

Aw

aiti

ng

Do

cto

rD

isch

arge

Aw

aiti

ng

Car

e H

om

eA

sses

smen

t

Aw

aiti

ng

soci

al c

are

asse

ssm

ent

and

…

Aw

aiti

ng

equ

ipm

ent

Aw

aiti

ng

Oxy

gen

Ass

essm

ent

Pat

ien

t re

fuse

dd

isch

arge

Aw

aiti

ng

Tran

spo

rt

Aw

aiti

ng

SALT

RRR audit - results

www.england.nhs.uk 7

50 50

50% of people have an LTC

70 30

70% of the health budget is

spent on LTCs

Long term conditions: some facts

www.england.nhs.uk 8

1mPeople with frailty

10mPeople have two

or more LTCs

0.35mAt end of life

16mPeople have one

LTC

Long term conditions: some facts

www.england.nhs.uk 9

0.01%average no. hours

per year spent

with a professional

33%of GP consultations are

with people with multi

LTCs

15%of young adults

aged 11-15 have

an LTC

3.2%of people with LTCs

have a care plan

Long term conditions: some facts

www.england.nhs.uk 10

50 50

96 4

50% of total emergency beds

days for over 75s

4% of over 65s in care home

2570 25% of hospital beds

occupied by someone dying

2013 2014 2015

Three-fold increase in cost

of health care with frailty

Long term conditions: some facts

www.england.nhs.uk

People living longer but not always well

The larger the number of co-morbidities a patient

has, the lower their quality of life

Social isolation/loneliness a risk factor for mortality in

over 75s

Increasing evidence on over-treatment and harm

And…

13/11/2015

www.england.nhs.uk

Wellbeing is about more than just medically managing a condition

It’s about thriving not just surviving

It’s an ethical, social and financial issue

Shared decision-making is key

We need to take support people to self-care, feel in control

No one knows more about their condition than the patient

12

Why does it matter to people with

LTCs?

www.england.nhs.uk

Develop a “orientation” process: about the condition(s), how to live with it, how to stay healthy and independent

Have a different conversations: ask a different question - what matters to you/me today

Use experience to inform decisions: plan on a page, 3 questions

Write letters to other services/clinicians together and share them with everyone involved in the care and support

Jointly create care plans that focus on the whole person and that are owned and move with the person

Help move through the system: care co-ordinator/navigator

13

Moving to person-centred care

together

www.england.nhs.uk

Person centred

coordinated care“My care is planned with people who

work together to understand me and my

carer(s), put me in control, co-ordinate

and deliver services to achieve my best outcomes”

Goal:

Improve quality of life and experience of

end of life care for people with Long

Term Conditions and their carers

through:

14

www.england.nhs.uk

LTC Strategy for Person Centred Care:

15

Care & Support Planning

Embedding personalised care and support planning

as the core component

EvidenceImproving evidence and implementation of it to

commission better care

EngagementRaising professional and public awareness of and engagement with PCC

Models of careIncreasing co-ordination and

continuity of care though development and testing of

new models

EnablersStrengthening the enablers that drive change including

data and incentives

InequalitiesFocussing on areas of

inequality – care homes, Neuro, MSK, palliative care for non-cancer conditions

www.england.nhs.uk

The vision

Transformational change:

A health and wellbeing

service, not just an illness

service

Giving people greater

control over their health

Harnessing innovation

including technologies

Moving away from a ‘one-

size fits all’ model of care

for people

Co-ordination of care

between services for all

that need it

Stronger commissioning to

focus on value (people

and system)

Supply of

Services Increasing costs

of providing care

Care delivered

around

organisational

boundaries and

disease

pathways

Separation of

commissioners,

contracts, funding

Constrained

public resources

Demand for

Services

Ageing

Society

Rise of long-

term

conditions

and multi-

morbidity

Increasing

expectations

Person centred

co-ordinated care

www.england.nhs.uk

Supporting self-care

17

No LTCs (yet)Single/dominant

condition

Multiple

conditionsEnd of life

25m 15 - 20m 5m 330k

'Brief

interventions'

Self - management

training and apps

PAM 1

Care and

support

planning

Advanced care

plans / advanced

directions

Access to

EHR

Digital care

plan

Year of care

funding

PHB 2

IPC 3

1. Patient Activation Measurement

2. Personalised Health Budgets

3. Integrated Personalised Commissioning

Wearables /

apps

Enablers:

Interventions:

www.england.nhs.uk

Framing delivery….

LTC Framework:

Empowered patient and carers

Professional collaboration

Best Practice (clinical and organisational)

Commissioning

Delivering Person Centred Co-ordinated

Care

www.england.nhs.uk

www.england.nhs.uk

The Framework

20

Organisational &

Clinical Processes

Informed and

engaged patients

and carers

Health & Care

Professionals

committed to

partnership

working

Commissioning

• Information and

technology

• Case finding & risk

stratification

• Care Planning

• Safety and

Experience

• Guidelines,

evidence and

national audits

• Self Management

• Patient activation

• Health literacy

• Information and

Technology

• Group and Peer

Support

• Care Planning

• Carer support

• 3rd sector support

• Community

mobilisation

• Integration of

services

• Multi Disciplinary

Teams

• Health coaching

• Culture (Clinical

activation)

• Workforce

development

• Care Planning

• Care Co-ordination

• Needs Assessment

and Planning

• Joint Commissioning

(IPC, YoC and

PHBs)

• Joint funding (BCF,

shared risk and

reward)

• New models of care

• Metrics and

Evaluation

• Service User and

Public Involvement

• Care Planning

Key factors needed to deliver Person Centred Coordinated Care and that are

being supported nationally: Care & support planning as the golden thread

www.england.nhs.uk

7

Using behavioural

change to open minds

Call to Action:

For clinicians to write to the person

directly and CC their GP rather than the

other way around

Tools and Resources:

• Slidedeck from Rob Elias, Kings

College Hospital uploaded to

slideshare

• Engage a few activated people on

twitter

Outcomes

Activating patients and staff to

• Support people to develop the

knowledge, skills and confidence to

manage their own health,

• Enhance their own sense of well being

• Develop skills to empower independent

living.

#A4PCC – Action for Person-Centred Care

Person with

long term

condition

www.england.nhs.uk

Our Declaration

Launched at Expo 2015

The importance of person-centred

care for people with long-term conditions,

what needs to change and why we need

to change

Co-produced with NHS England and

Coalition for Collaborative Care and

developed with health and care

professionals, policy makers and people

with long-term conditions

To motivate and support health and

care professionals to help us make it a

reality

#A4PCC – Action for Person-Centred

Care

www.england.nhs.uk

What part will you play?

Make your declaration at

www.engage.england.nhs.

uk/survey/ltc-declaration

#A4PCC – Action for Person-Centred

Care

YOU CAN MAKE A DIFFERENCE

www.england.nhs.uk

@jaqwhite1

#A4PCC

jacquie.white@nhs.net

www.england.nhs.uk/resources/resources-for-ccgs/out-frwrk/dom-2/

24

Thank you