NHS South East Coast
Long Term Conditions Programme
LTC Personal Care Planning Pilot
Project Evaluation
Final
August 2011
Project Clinical Lead Programme Manager Dr Greg Rogers Gordon Houliston
Version Control
Update history
Version / Created by / Main Changesv0.1 / Gordon Houliston / Dr Greg Rogers / Created initial draft –
v0.2 / Gordon Houliston / Dr Greg Rogers / Dr Michael Pick – Key changes and minor ommission requested made.
Liz Lawn – Minor change to risk profiling method used by practice made.
Kathy Edwards – Addition of cost per care plan made.
V0.3 / Gordon Houliston / Dr Greg Rogers / -Ammendment to executive summary
-New para inserted section 1.1
-Removal of section 1.2 ‘The NHS challenge for long term conditions’.
-Minor wording changes to section 2.2
To be reviewed by
Reviewer / Organisations / StatusKaren Devanny / NHS SEC, LTC Programme Lead / Reviewed
Dr Greg Rogers / NHS SEC Primary Care LTC Clinical Lead / Reviewed
Julie Gardner / Commissioning Manager for NHS Surrey / Reviewed
Dr Liz Lawn / GP, LTC Clinical Champion for NHS Surrey / Reviewed
Ann Younger / Commissioning Manager for NHS West Sussex / Reviewed
Sheila Pitt / Head of Cancer, LTC and Therapies Lead Commissioner for NHS Eastern and Coastal Kent / Reviewed
Dr Michael Pick / GP, LTC Clinical Champion for NHS Eastern and Coastal Kent / Reviewed
Sue Nunn / Fund Advisor, The Young Foundation / Reviewed
All / Local Implementation Teams / Reviewed
Table of Contents
Acknowledgements...... 4
Executive Summary ...... 5
1Introduction ...... 8
2Planning and Delivery ...... 12
3Practice Case Studies...... 17
4Practice Observations...... 25
5Results...... 28
6 Themes ...... 35
7 Discussion / Conclusion ...... …39
8 Recommendations ……….……...…………………… ……………42
9 Glossary...... 44
Appendix A: Template...... 46
Appendix B: Oberoi Consulting Report...... 52
Appendix C: Full Bridge Practice Case Study………………..………53
Appendix 3: Diabetes UK Definition...... 60
Appendix 4: NICE Definition...... 61
References ...... 64
Acknowledgements
We would like to thank the following colleagues for their contribution to the project and its evaluation;
Dr David Hopkins – GP (Victoria Road)
Jane DeJong – Practice Manager – (Victoria Road)
Caroline Nelson – Contracts Manager (Victoria Road)
Liz Phillips – Nurse (Victoria Road)
Peter Fitzgerald – Nurse (Victoria Road)
Sarah Heale – Commissioner – (NHS West Sussex)
Anne Younger – Commissioner – (NHS West Sussex)
Jacqui Nettleton – LTC Programme Lead (NHS West Sussex)
Dr Michael Pick – GP (East Cliff)
Sheila Forster – Practice Administrator (East Cliff)
Ian Macdougald – Managing Partner (East Cliff)
Harry Dewey – Information Analyst (NHS ECK)
Dr Liz Lawn – GP (Bridge Practice)
Nicole Haider – Practice Administrator (Bridge Practice)
Julie Gardner – Commissioner – (NHS Surrey)
Nicholas Maloney – Information Analyst (NHS Surrey)
Sue Nunn – Fund Advisor – The Young Foundation
Katherine Cheema – Specialist Information Analyst (NHS SEC)
Karen Devanny – LTC Lead (NHS SEC)
Alison Lorimer – Head of NCB Transition (NHS SEC)
Katie Harrison – Communication Officer (NHS SEC)
Mark Hannigan - Regional Program Manager (NHS Diabetes)
Kavita Oberoi – Managing Director (Oberoi Consulting)
Nicky Beardmore – Regional Account Director (Pfizer)
Karen Ashenden – Regional Account Manager (Pfizer)
Ray Wagner – Management Consultant – (RL Wagner Ltd)
Executive Summary
The rising health care challenge to the NHS of long term conditions (LTC) is with us and supporting patients living with chronic conditions is a key strategic priority for NHS South East Coast (SEC).
Over the past 12 months 3 GP practices in SEC have been piloting motivational interviewing as a way of enabling LTC patient’s to develop a personal care plan. Motivational interviewing is a client-centred approach to enhancing patient motivation to change; the spirit of the approach is collaborative in nature, communicating in a partner like relationship. The project also used risk stratification to identify key groups, with each practice using the approach with 100 patients.
Personal care planning is essentially about addressing the full range of patient needs, recognising that there are often other concerns in addition to medical needs that impact and contribute to a person’s health and well-being. The project focused on empowering patients participating in the pilot to achieve set goals and objectives which would either directly or indirectly improve their overall health and wellness, promoting health and independence through information and self care.
The key objectives were to design a process that would work effectively in primary care, whilst trying to gain a greater understanding of the organisational and operational implications of following a personal care planning process, including the identification of gaps in workforce skills, education and training. The pilot also set out to test the benefits of utilising a full, single long term conditions disease register enabling practices to stratify patients according to need/risk. As a quality initiative the pilot hoped to gain a greater understanding of the patient and system benefits that result from personal care planning as an intervention for patients living with long term conditions.
The final intention was to understand the operational and financial implications of wider roll out across the SEC region. Innovation projects, by their very nature are about trying new approaches. The concept of personal care planning was at this point a relatively new approach being tested, and as such there was a need to fully measure success and adjust the method based on the experiences of the practices before planning to mainstream.
The project set out to pilot the intervention on patients with a range of long term conditions, which included; Asthma, COPD, Chronic Kidney Disease, Cancer, Dementia, Diabetes, Depression, Epilepsy, Heart Failure, Hypertension, Ischaemic Heart Disease, Mental Health, Motor Neurone Disease, Obesity, Parkinson’s Disease and Stroke. From the outset the focus was on identifying patients who would clinically benefit from a personal care plan, moving away from managing single conditions to a much more holistic approach. This supported the national LTC drivers of promoting self management, using risk profiling to identify those patients with the greatest need and where possible integrated working between providers.
The strength of the pilot was that the intervention was implemented in three very different ways. Each pilot site chose to use the clinicians they felt were appropriate to work in partnership with the patients to deliver the personal care plan, this ranged from GP’s, practice nurses to specialist community nurses. This enabled a wider set of tests with the project team able to quickly learn by comparing and contrasting the strengths of their approach as well as the problems and barriers each practice encountered. The learning approach to the pilot was further facilitated by the project clinical lead, Dr Greg Rogers, observing personal care planning sessions at each practice, to be able to consider the different ways the intervention had been implemented.
The pilot had to clearly demonstrate that the intervention brought value to both patients and the system whilst making the distinction from what is currently available to LTC patients. Due to the approach (inviting patients to participate) the benefits tracking concentrated on patient and healthcare professional experience.
Two sets of questionnaires were conducted as part of the evaluation, the first relating to the patient and how they felt about their ability to manage their condition(s) and how aspects of the personal care planning process have impacted on that. The second questionnaire concerns how the healthcare professionals carrying out the care planning felt about its utility and impact on their patients and practice.
Taken as a whole, the patient experience data appears to suggest the main goals of the personal care planning process were achieved with the majority of patients who responded feeling able and motivated to manage their own condition. The healthcare professional response was mixed, with the professional group to which respondents belonged being the key factor. On all questions, GPs presented a far lower proportion of positive responses than practice nurses. It is interesting to note that in the areas where GP’s delivered the personal care plan the patients’ responses reflected far more positive outcomes than their healthcare professionals’.
Drawing conclusions on system wide benefits has proven difficult due to the nature of inviting patients to attend a personal care planning consultation and also the length of the pilot. Practices were not in a position to undertake a secondary care baseline until all patients identified as suitable had actually attended the appointment. The length of pilot was another factor contributing to the difficulty in making robust conclusions around the benefit to the health economy of personal care planning.
The key usage of the secondary care data was to quantify the impact of personal care planning in terms of capacity and return on investment. It was agreed by the project group that those patients identified would require further analysis of secondary care data in 12-18 months time. This was felt to be a reasonable timeframe by which to draw conclusions around the impact of personal care planning on the patient. The qualitative approach will go some way to adding to the quantitative picture created by the patient and clinician feedback.
Taking on board the experiences of patients, clinicians and practice staff involved in the pilot, a number of recommendations were formed following an evaluation event which included input from all stakeholders.
Firstly, personal care plans can offer an additional tool to those involved in a patients care to promote independence. It was agreed that to gain maximum benefit the intervention should be adopted as soon as possible from the diagnosis of a long term condition and evolve with the patient in time with emphasis initially on information through support and then if required continuing care.
The ownership of personal care plans sits with the patient and this should repeatedly be focused upon. This recommendation follows experience in the pilot sites that found that there is a risk of their focus being taken over by healthcare professionals. This can have the result of weakening the role of personal care plans to motivate self care. A further risk is that the ‘personal care plan’, itself rather than the ‘personal care planning process’, can become the focus. This has the added consequence of adding yet more paperwork to clinicians whilst losing sight of patient goals and aspirations in the process.
Motivational interviewing was accepted by all involved as an essential skill required by healthcare professionals delivering personal care planning. It would be useful to evaluate where motivational interviewing is best placed in managing health care and learning more how best to use this powerful tool. If motivational interviewing is used routinely as a consulting style the time constraints largely disappear as it becomes standard practice. We would strongly recommend more work be specifically focussed on motivational interviewing with educational events to support its wider use.
For some people with a long term condition the aspirations and goals created in the personal care plan can be realised through a personal health budget. A personal health budget allows people to have more choice, flexibility and control over the health services and care they received. The roll out of personal care plans and personal health budgets would surely benefit from joining the two work streams together and would be a step towards conditional resource entitlement whereby social care and health care are reformed to allow support to individuals usually allied to outcome.
If personal care plans continue to be rolled out across the NHS consideration should also be given for patients who decline or where clinical judgement identifies them as likely not benefiting for a personal care plan. Key performance indicators could be aligned to outcomes for that patient rather than simply counting the number of people who own a personal care plan.
In general practice clinicians may find it more economical for health care assistants trained in care planning to commence the personal care plan and identify areas to focus on where it may be required for more specialised clinicians to deal with these issues later on. Patient records need to be structured in a way that gives a clear indication of unresolved problems so that they do not become buried in paperwork.
There was generally thought across all pilot sites to be a lack of information on local services which hindered healthcare professionals confidently signposting patients to local services that may assist the patient in achieving goals set. Once a need has been identified it is important to have an easily accessible and up-to-date directory of services available to enable sign posting of patients to suitable care. Also if a patient identified a need that could be met by provision of a suitable personal health budget a broker should be easily accessible to plan and broker this need for submission on behalf of the patient.
The aforementioned recommendations are based on the experiences of the pilot project and should be considered by PCT Clusters when taking forward individual plans around the personalisation of services for patients with long term conditions.
1. Introduction
1.1Background
In line with Department of Health (DH) policy NHS South East Coast (NHS SEC) agreed a number of ambitious pledges in its strategy ‘Healthier People, Excellent Care’ (HPEC) to introduce more personalised care to support independent living and quality of life. Regionally NHS SEC further pledgedthat ‘by 2011, 90% of those with complex long term conditions will be identified and able to manage their own personalised and negotiated care plan. Case manager support will be provided when necessary’.[1]
Through a programme management approach programme leads with local clinical champions were responsible for delivering improvements in services for those living with long term conditions South East Coast wide.
In October 2009, Dr Greg Rogers (a Margate based GP ), submitted a formal bid for funding to NHS SEC’s Regional Innovations Fund (RIF) that was co-ordinated at regional level and focused on improving the care of patients with LTCs. The original bid, which was supported by NHS Eastern and Coastal Kent (NHS ECK), NHS West Sussex (NHS WS) and NHS Surrey, aimed to investigate ways of rationalising many of the existing myriad of primary care ‘Locally Enhanced Services’ (LESs) to create a single over-arching LTC LES that would not only support enhancements in quality of care but would also provide an effective delivery mechanism for NHS SEC’s regional HPEC pledges for people living with LTCs.
Dr Rogers successfully secured funding and clinically led the project which involved the risk stratification of patients with LTCs in 3 pilot GP practices across SEC, offering personal care plans for 100 patients with a further 100 patients set as a comparator group. The project was designed to assess whether this new form of service provision / intervention was achievable in primary care and also to gain some idea as to the benefits it would bring to patients with long term conditions.
Personal care planning invites the person living with the long term condition to be at the centre of their care and describes the outcomes they want to achieve and what help they envisage is needed to reach their personal goals.
The Department of Health (DH) have made it clear in national policy their desire to develop greater personalisation of health care services ensuring that users of the health service have a greater say in deciding the care that best meets their needs. This project, by focussing on personalisation of care, helps to develop this picture more clearly both in terms of implications for delivery of care but also offers to help evaluate changes in outcomes that follow such a process.
1.2‘Year of Care’
Diabetes UK was very influential in developing the personal care planning model and promoted a ‘Year of Care’ care planning project. This patient support group recognized that care planning was not to be seen as an end in itself.
The value of engaging people with diabetes or any long-term condition in their healthcare and self-care components is supported by a wealth of evidence. It is at the heart of partnership working. It is looking with, rather than at someone with diabetes. In the context of Year of Care, care planning is also a means to an end. The care planning consultation will identify what each individual needs to support them to self care effectively. [2]
They saw clearly the value of having information about a patient shared by all those who were involved in that person’s care and also the link to personal health budgets as a result of the personal care plan. This group also focused on the care planning being a verb and not a noun, being a collaborative ongoing process rather than a product called a ‘care plan’. This diagram from the document captures well this ethos;