NHS LONG TERM PLAN
days) and their treatment and care absorb 70% of acute and primary care budgets in England.
The NHS states that it’s clear that current models of dealing with long term conditions are not sustainable. Rather than people having a single condition, multimorbidity is becoming the norm.
The barriers to great care for people with long term conditions have been identified by a wide range of reports and reviews, and can best be summed up as failure to provide integrated care around the person. NHS England and partners are using the ‘House of Care’ model as a checklist/metaphor for building blocks of high quality person- centred coordinated care. The House relies on four key interdependent components, all of which must be present for the goal, person- centred coordinated care, to be realised: l Commissioning – which is not simply procurement but a system improvement process, the outcomes of each cycle informing the next one
l Engaged, informed individuals and carers – enabling individuals to self-manage and know how to access the services they need when and where they need them
l Organisational and clinical processes – structured around the needs of patients and carers using the best evidence available, co- designed with service users where possible
l Health and care professionals working in partnership – listening, supporting, and collaborating for continuity of care.
The House of Care model (based on the Chronic Care Model of Ed Wagner, and the Diabetes UK Year of Care project) is useful for drawing together the building blocks of integrated care to include the essential elements of continuity: l Informational continuity: by which people and their families/carers have access to information about their conditions and how to access services; health and social care professionals will have the right information and records needed to provide the right care at the right time
l Management continuity: a coherent approach to the management of a person’s condition(s) and care which spans different services, achieved through people and providers drawing up collaborative care plans l Relational continuity: having a consistent
philosophy behind the care which commissioners wish to provide eg: National Voices ‘I’ statements?
l Which: Which populations of people with LTCs require a customised House of Care approach due to their particular care needs, and how will they be identified (e.g. risk stratification approaches, GP disease register, frailty index etc)
l Where, When, and Whom: Decide the local model of care i.e. where and when will all the components of the House be delivered for each group of people, and by whom
l How: Write the specification of how to achieve this including the financial model that will support what needs to be done (tariffs, contracts, incentives etc that match the model of care)
relationship between a person, family, and carers and one or more providers over time (and providers having consistent relationships with each other), so that people are able to turn to known individuals to coordinate their care.
Applying the House of Care
The House of Care model is suitable for all people with long term conditions (LTCs), not just those with single diseases or in high risk groups, and for frontline clinical practice, supported by local and national policy and strategy.
There are at least three levels at which the House of Care model can be used: 1 Personal level: How the House of Care gives professionals on the front line a framework for what they need to do along with the people for whom they provide care and other providers, and ask local commissioners to secure for them (i.e. based around care planning discussions to jointly select the particular services which will help a particular person achieve their goals).
2 Local/community level: How can local health economies make sure that the House of Care involves a ‘whole system’ approach to provision of services, including ‘more than medicine’ offers (community links with social care, housing, transport, employment etc). This will need commissioners to decide on:
l What: What are the principles and
In diabetes care, where many patients come into contact with a number of clinical and support teams, the need to drive this kind of integration and efficiencies is stark. The ability to interface and share information between departments has an enormous positive impact on patient care.
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3 National level: what national organisations such as NHS England and its partners do to enable construction of the House of Care (at the community and personal levels).
Interoperability and diabetes care
In diabetes care, where many patients come into contact with a number of clinical and support teams, the need to drive this kind of integration and efficiencies is stark. The ability to interface and share information between departments has an enormous positive impact on patient care. Diabetes is a huge priority for the NHS, both in terms of reducing the number of people with the condition and the cost of treating them – NHS England cites diabetes as “one of the major clinical challenges of the 21st century.”4
The condition accounts
for 10% of all NHS expenditure and the number of newly diagnosed Type 2 diabetes patients is growing at an alarming rate – almost doubling in the past 20 years.5
It’s
estimated that over 4.7 million people in the UK6
In terms of the treatment of Type 2 diabetes – the form of the condition that is rising – education and establishing systems that enable self-management are seen as key to tackling rising levels and associated costs. It’s also a condition associated with high levels of complications, with the prevalence of comorbidity also high. Having one shared patient record that can be accessed by multiple clinical teams across primary and acute care allows for better and easier management of the growing numbers of patients by healthcare providers. Electronic information management systems have been successfully adopted by diabetes teams and have helped Trusts reduce both HbA1c levels and the proportion of CYP in DKA at diagnosis in both adult and paediatric care. They are now routinely used to record a range of clinical datasets to monitor patient performance against Quality Standards7
have a form of the condition, with older people being more at risk. If levels of diagnoses continue to rise at the same rate, by 2030 there will be 5.5 million people in the UK living with the condition.6
and NICE guidelines.8 EMRs are also used to conduct monthly OCTOBER 2019
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