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

2. The Year of Care
programme: Evidence and
experience
The Nuffield Trust & NHS Confederation
10 September 2009

3. PANEL
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)

4. 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 challenges
Discussion
• The next steps / round up

5. The aspiration
• NHS National Plan:
2000
Step 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.

6. The aspiration
The Wanless Report 2002
• The Fully engaged scenario
• Every £100 spent on self
care saves £150

7. 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”

8. The reality
Is the NHS becoming more patient centred?
Picker- September 2007

9. The reality: Diabetes
had at least one check
up in the last 12
months
and
discussed 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
From ‘Managing Diabetes’ Healthcare Commission: 2007 diabetes

10. Doing something different?
addressing
the gap?
From ‘Managing Diabetes’ Healthcare Commission: 2007

11. 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

12. 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

13. 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’

14. 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.

15. The key role of care planning in linking clinical care and
commissioning
Individual patient choices
via the care planning
process = micro-level
commissioning
MENU OF OPTIONS
Examples
• Education
• Weight management
• Screening for
complications Macro-level commissioning by
the commissioner
• Telephone (PCT/practice) on behalf of the
review/support whole diabetes population
• Smoking cessation
advice
• Local authority
exercise programme
• Specific problem
solving
• EPP
• Buddying / walking
groups…
‘An end in itself’ ‘A means to an end’

16. NORTH
OF TYNE
• 39 practices
• 3 PCOs
• Rural and
urban
CALDERDALE
communities & KIRKLEES
• 6 practices
TOWER • Primary and
HAMLETS Secondary
Care
• 8 practices
• Significant
• Diverse health
communities inequality
• High and low
levels of
deprivation

17. 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

18. 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

19. The key models
Firstly care planning ….
…and then commissioning
The care
planning
consultation
Commissioning
- The foundation
The ‘House’
The ‘Windmill’

20. Learning and sharing:
the biggest issue
Getting the ‘language right!’

21. 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?

22. Need common understanding
of…
• “Patient centred”
• “Support for self management”
• “Components of a diabetes service”

23. Care plans vs. care planning
• 2004 National LTC
target
• Reduction in
emergency beds days
via care coordination
and care plans
• Community matrons

24. Care plans and care planning:
A continuum
•Often asymptomatic
•Frail and symptomatic •Aim: prevention of
deterioration
•Aim: Care coordination
•Support for self management
•Service main ‘actor’
•Individual is main ‘actor’
•Care plan critical
•Care planning critical
‘it’s the noun!’
‘it’s the verb!’
2004 national target
Year of Care

25. Commissioning headings for Long Term Conditions
Traditional biomedical care.
= the ‘financial •QoF / checklists
envelope’/
programme budget •Complex care
•‘doing to’
Individual
needs
Consultation 1:1
Self care / self management
•Care planning / goal
setting •Living with diabetes
Year of Care
•Joint decision making •Lifestyle issues
•Collaboration •Community support
•‘doing with’ •Social capital

26. 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’.

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

28. Patient focussed care
planning
Avril Surridge

29. 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.

30. Patient focussed?
• Patient at the centre.
• Planning care around the needs and
wants of the individual patient.

31. 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!

32. 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!

33. 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.

34. 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.

35. Care Planning
Information gathering
Information sharing
And discussion
Goal setting and
action planning
Agreed & shared
care plan

36. HCP committed to
HCP committed to
HCP committed to
partnership working
partnership working
partnership working
- The foundation
Commissioning
Organisational
The care planning
processes
consultation
Engaged,
Engaged,
Engaged,
informed patient
informed patient
informed patient

37. IT: clinical record of care planning
Send test results Contact numbers
beforehand Organisational and safety netting
processes
partnership working
‘Prepared’ for Consultation
HCP committed to
informed patient
consultation Engaged, skills / attitudes
Information/ Integrated,
Collaborative
Structured multi-disciplinary
care
education team & expertise
planning
consultation Senior buy-in &
Emotional &
psychological local champions
support to support & role
model
Commissioning
- The foundation

38. 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.

39. Qualitative study

40. Patients and professionals
I could focus on the I enjoy doing the clinic
important things for a lot more now…
me and get help working with them
rather than at them
Took the ‘cork out of
People feel
the bottle’
more
relaxed
Time to read [results]
and think about what It’s absolutely 100%
to raise… you know better for me and for
what was coming the patients

41. Organisational
processes
partnership working
HCP committed to
informed patient
Engaged,
Collaborative
care
planning
consultation
Commissioning
- The foundation
Identify Procured time for Quality
and fulfil consultations, assure and
needs training, & IT measure

42. Summer 2009: A complete package
Making 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?

43. Challenges from healthcare
professionals… maybe you too?
We do it My patients
already! don’t want it
What if they
Will it
don’t do what
work?
I think they
should do?

44. Challenges from
Commissioners….maybe you too?
I want to see I don’t have time
in year to do all this for
savings one condition
This will This isn’t all
make
inequalities
in our
worse priorities with
SHA

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

46. Session overview
1. Micro to macro
2. A whole systems approach
3. Developing new and existing provider to
support self management,
4. Identifying costs
Dr Douglas Russell

47. Improving diabetes care in Tower Hamlets is
a top priority
Diabetes in TH – key facts
• Diabetes register ~ 11,000 in TH CSP goal for diabetes
• 1,700 – 2,200 undiagnosed
• Prevalence expected to rise 1% • Our goal is to ensure 69% of all
patients on the diabetes register
per year for the next 10 years
have HbA1c < 7.5% (i.e. blood
• 53% of diabetics are Bangladeshi
sugar controlled) by 2013
• TH population is 15% more likely to
have diabetes
• The evidence suggests that
controlling lifestyle factors has a
Diabetes attributable deaths (% of all deaths, significant impact on diabetes-
20-79 year olds), 2005 data related complications and mortality
16.0 16.0
13.6 12.0 • However it is not entirely clear that
HbA1c is the best indicator of
control…
INEL TH London England
Rank 2 - 27 150
/3 /29 /152
Source: THPCT, NHSL, Vital Signs guidance, QOF – Information Centre for Health and social Care, YHPHO

48. Variation across practices is
significant and exception reporting
is high 2008/09 Q4 HbA1c<7.5 with and without exceptions
Q4 w ithout Exceptions
Q4 w ith Exceptions
WHITECHAPEL HEALTH
VARMA, CM
ST PAULS WAY PRACTICE
EAST ONE HEALTH
ALBION HEALTH CENTRE
STEPNEY GREEN MEDICAL
SELVAN N
ABERFELDY PRACTICE
ISLAND MEDICAL CENTRE
JUBILEE STREET PRACTICE
NISCHAL VK
ALL SAINTS PRACTICE, THE
BLITHEHALE MEDICAL CENTRE, THE
XX PLACE
Tow er hamlets
HARLEY GROVE MEDICAL CENTRE
ST STEPHEN'S HEALTH CENTRE
BARKANTINE PRACTICE, THE
RANA AK
SPITALFIELDS PRACTICE
MISSION PRACTICE
GLOBE TOWN SURGERY
TOWER MEDICAL CENTRE
BETHNAL GREEN HEALTH CENTRE
STROUTS PLACE MEDICAL CENTRE
POLLARD ROW PRACTICE
AMIN NB
WAPPING GROUP PRACTICE
DOCKLANDS MEDICAL CENTRE
TREDEGAR PRACTICE
SHAH KP
LIMEHOUSE PRACTICE
ISLAND HEALTH
STROUDLEY WALK PRACTICE
ST KATHARINE'S DOCK PRACTICE
0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0%
Source: THPCT, NHSL, DH

49. We stratified patients based on clinical
criteria…
1 4
Criteria for newly diagnosed Complex off-target
Newly diagnosed in the first Off target and
6 months or newly Renal, Limb, & Eye
diagnosed in second 6 Depression
months not controlled
Currently 13% of patients
Currently 8% of patients
2 3
Criteria for controlled Off-target
>6 months diagnosed and Off-target Clinical parameters that
all three conditions met exceed any or all of:
BP<=140/80 BP>140/80
HBA1C<=7.5 HBA1C >7.5
Cholesterol <=4.5 Controlled Cholesterol >4.5
mmol
Currently 53% of patients
Currently 27% of patients
SOURCE: Diabetes care package group; EMIS web data

50. TH is addressing the challenge
through several initiatives
1) Education Programme (Jan-May
1
2 2009)
2) Care planning being implemented in
3
all practices
3) Old LES updates to reflect care
4
package components
4) Care packages in waves (Wave 1 –
Sept, Wave 2 – Jan, Wave 3 – April)

51. Best practice education
programme
TH needed better diabetes education Education programme - £1.3m investment
Education for people with diabetes is Aims:
established in the literature as a high • Reach 70% of the known 11,140
impact intervention, but programmes at
TH suffered from diabetes in TH
• Low referral rate • Raise patient awareness
• Poor uptake and completion rate • Increase referrals by health
• High attrition rate professionals
• No choice • Offer tailored programmes
• High cost Interventions:
• 2 hour Key message Course
Uptake of education previously poor
• HAMLET structured course 4 x 3 hour
% responses to Health Care Commission survey*
sessions
• Healthy Moves exercise and cookery
Attended education 14%
classes
• DVD and work book in 3 languages
Did not attend 86%
• Drop in sessions
84% Never offered
Outcomes:
• 9,940 total attendances
16% Other reasons
• 100% received a DVD and workbook
• Events held at 52 venues,7 days per
SOURCE: Healthcare Commission survey, 2006, THPCT week in 18 languages

52. The care package was developed to address the
problems we faced with the previous LES
Old LES Care package
• Diabetes outcomes in Tower • Creates processes to ensure
Hamlets are among the worst peer support and challenge
in the country due to the
demographic characteristics • Attaches financial incentives to
of our population agreed minimum standards
• The previous LES did not • Dashboard ensures incentives
provide a means of are tied to the right outcomes
incentivising practices to
collaborate • Provides a more robust
performance management
• Good practice was not shared system than the LES
systematically and this
generated inequality • Data sharing to improve
management processes

53. Linking Micro- to
Macro-commissioning
Issue: Goals: Action: Outcome:
No. with Wanted to Wt loss No. with >5%
BMI >30 lose weight intervention weight loss
100 50 30 12
A: 10 6
Gap: B: 10 4
20 C: 10 2

54. Customised IT support

55. The Commissioning Windmill


56. Care planning and clinical care

57. Specific tailored information to
support care planning

58. Needs assessment

60. User involvement

61. Local involvement
North
Tyneside
User Group
Engaging in Calderdale &
Kirklees
the wider
Diabetes UK
community voluntary group
Local
people and
groups
People with
diabetes on Focus groups
project for carers
boards Tower
Hamlets
patient
events

62. Provider Development

63. Summary of local engagement

64. 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

65. National PCT scores against WCC competencies
1 Locally lead the NHS
2 Work with community partners S
W 3 Engage with public and patients
T
E 4 Collaborate with clinicians
R
Manage knowledge and assess
A 5
needs
O
K 6 Prioritise investment
N
7 Stimulate the market
E
8 Promote improvement and innovation G
R
9 Secure procurement skills E
10 Manage the local health system R

66. 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’

67. 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.

68. Over to you.

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