110614 tim warren presentation
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Tim Warren PresentationTRANSCRIPT
Self Management and the Quality Strategy
Tim WarrenLong Term Conditions Unit
Scottish Government
Leading Change for the Future, June [email protected]
BBC RADIO 4 30th May 2011 ANALYSIS: UNHEALTHY EXPECTATIONS?
• Presenter: Michael Blastland
• John Appleby - Chief economist at the King’s Fund
• Sir John Oldham - GP & NHS clinical lead on quality and productivity
• Dr Lise Llewellyn: Chief executive of NHS Berkshire East
Demographics• OLDHAM: There is going to be a 252% rise in
the number of people with chronic diseases between now and 2050. If we take just the next four years, of the existing people with chronic diseases there’ll be a 60% rise in the number of people who have two or three conditions. On current projections of expenditure, it’s the US I think who by 2065 will spend 100% of GDP on healthcare.
• BLASTLAND: So, 100 … The whole national economy, on current projections?
• OLDHAM: Yes. US first, Japan second. We’re in the middle of the pack. That’s what I mean by the “tsunami of need”.
Rising expectations
• GLENNERSTER: I think it’s unbelievable that in twenty years time people will be prepared to accept the standards of care that people are now receiving in geriatric wards or in long-term care. I mean these will just in retrospect be considered inhuman. People are just not going to stand for that.
Sustainability
• BLASTLAND: What does that do to the NHS?
• OLDHAM: If we continue to manage people with chronic diseases as we do now, the NHS and the social care system is not sustainable. Period.
Doing things differently
• LLEWELLYN ……there’s less money to go into the NHS and it’s going to be very difficult, ….We’re going to do (manage) by doing things differently, and I think that’s what we have to work with - the public and patients - is to understand that by doing things differently, by investing in the community, by investing in prevention, actually we don’t need to have as many crises, as many admissions into hospital. But it is a difficult message.
And competitiveness• OLDHAM: 70% of our existing health and
social care costs go to help manage people with chronic diseases now. That is this minute. They account for the majority of bed days in hospital, they account for the majority of visits to GPs. Not just this country, but lots of countries. In fact I would go so far as to say that the way that a country manages the people it has with chronic diseases will be a determinant of its competitiveness as an economy because the numbers are that big and the amount of resource going into it is that big.
And Self Management• OLDHAM: I go back to that statistic at the
beginning: There is going to be a 252% rise in the number of people with chronic diseases between now and 2050. Embracing people to help manage their condition themselves is the mechanism by which we achieve their expectations.
• Your personal expectation is met by you having control over how you manage your own condition, by you pulling in the expertise as and when you need it as an individual patient. That’s the future that we need to get to - aided and abetted by technology, which I believe will start to revolutionise the way that we manage people.
And Self management• OLDHAM: I go back to that statistic at the
beginning: There is going to be a 252% rise in the number of people with chronic diseases between now and 2050. Embracing people to help manage their condition themselves is the mechanism by which we achieve their expectations.
• Your personal expectation is met by you having control over how you manage your own condition, by you pulling in the expertise as and when you need it as an individual patient. That’s the future that we need to get to - aided and abetted by technology, which I believe will start to revolutionise the way that we manage people.
Quality Strategy • Better Health Better Care development• Integrated rather than additional• Aligns policy, planning and performance• For all of us - NHS, partners and public• For the long haul
Built on people’s priorities• caring and compassionate health services
• collaborating with patients and everyone working for and with NHSScotland
• providing a clean and safe care environment
• improved access and continuity of care
• confidence and trust in healthcare services
• delivering clinical excellence
Our approach
3 Quality Ambitions• Person Centred
Mutually beneficial partnerships between patients, their families and those delivering healthcare services, which respect individual needs and values and demonstrate compassion, continuity, clear communication and shared decision-making.
• Safe
No avoidable injury or harm from the healthcare they receive, and that they are cared for in an appropriate, clean and safe environment at all times.
• Effective
The most appropriate treatments, interventions, support and services will be provided at the right time to everyone who will benefit, with no wasteful or harmful variation.
Quality Delivery Groups - roles
• 4 Delivery Groups – Safe, Person-centred, Effective and Infrastructure
• Each identifying a portfolio of high impact, aligned and coherent priorities
• Developed from existing groups where possible, and stand down a number of remaining groups
• Each to link with the other 3 Delivery Groups• System-wide coherence - support NHS Boards to
drive improvements locally – e.g. by accelerating and spreading the successful approach of SPSP
Aim Quality Delivery Groups Initial Priority Areas For Action
Scotland is a World leader in
Healthcare Quality
Person Centred
Safe
Effective
Promote Person Centred Care through 4 Action Groups• Enabling Person Centred Care• Communication and Collaboration• Improving Experience and Outcomes • Supporting Staff Experience
Deliver an agreed set of effective and efficient
interventions through 3 Action groups : • Children and Families • Improving Population Health• Reshaping Care
1. Accelerate Patient Safety Programme2. Roll out across mental health, paediatrics, and
primary care3. Integration of action to reduce occurrence of HAI
1. Communication 2. Quality Measurement Framework3. Quality HUB4. Governance5. Workforce Development6. IT/eHealth
Quality infrastructure
Quality Delivery Groups – activity
• Prioritise improvement activity which simultaneously has a high impact on quality and supports system wide cost reduction – challenging and accelerating existing programmes and identifying and filling gaps where appropriate.
• Assess impact on inequalities and on the ‘other’ 2 Quality Ambitions
• Identify requirements for infrastructure support (workforce training/skills, IT, measures, communications, HUB, governance)
• Report progress and issues to Quality Alliance Board
Quality AllianceBoard
PersonCentredDelivery Group
SafeDelivery Group
EffectiveDelivery Group
Quality Infrastructure
Delivery Group
Efficiency and Productivity
Strategic Oversight
Group
NMAHPQuality Council
Delivering Quality
inPrimary Care
National Planning Forum
Chief Executives
Health Management
Board
Quality and Efficiency
Quality Outcome Indicators
HEAT
Supporting local and national quality measures
6 Quality Outcomes
• Everyone gets the best start in life and is able to live a longer healthier life
• People are able to live well at home or in the community
• The best possible use is made of available resources
• Everyone has a positive experience of healthcare
• Staff feel supported and engaged• Healthcare is safe for every person, every
time
Reshaping Care: Scotland 65+ Health and social care expenditure (07/08 total=£4.5bn)
Other Social Work
Care Homes
Home Care
FHS
PrescribingCommunity
Other Hospital care
Emergency admissions
£1.4bn
£0.8bn£0.4bn
£0.4bn
£0.4bn
£0.3bn
£0.6bn
£0.2bn
High Performing Systems
Chris Ham: Health Economics Policy and Law 2009
Characteristics 1-5
• Ensure universal coverage• Provide care that is free at the point of delivery • Focus on prevention not just treatment• Put Primary care at the heart of delivery • Give priority to help people self manage their
conditions with support from carers and families
High Performing Systems
Characteristics 6-10
• Balance population health and personalisation
• Integrated care• Technology and IT enabled • Coordinated care • 10 characteristics linked as a strategic
approach
King’s fund report
• Self-management support can be viewed in two ways: as a portfolio of techniques and tools to help patients choose healthy behaviours; and a fundamental transformation of the patient–caregiver relationship into a collaborative partnership (De Sliva 2011, p vii).
Prevention and Self management is high priority in
Scottish Government
•Blurring lines between professionals and people – de mystifying medicine
•Blurring lines with preventative care
Moderately well controlled Moderately well controlled ---single condition single condition –– 7070--80% 80%
of LTCof LTC
Intensive Case/ Care Intensive Case/ Care ManagementManagement
Disease/ Care Disease/ Care Management Management
Population Wide Prevention, Health Improvement & Population Wide Prevention, Health Improvement & Health PromotionHealth Promotion
Targeted High Targeted High Risk Primary Risk Primary PreventionPrevention
Self Self ––Management Management
Complex coComplex co--morbidity morbidity –– 33--5% of LTC5% of LTC
Poorly controlled single Poorly controlled single condition condition –– 1515--20% of LTC20% of LTC
At high risk of At high risk of CVDCVD
33
22
11
00
Moderately well controlled Moderately well controlled ---single condition single condition –– 7070--80% 80%
of LTCof LTC
Intensive Case/ Care Intensive Case/ Care ManagementManagement
Disease/ Care Disease/ Care Management Management
Population Wide Prevention, Health Improvement & Population Wide Prevention, Health Improvement & Health PromotionHealth Promotion
Targeted High Targeted High Risk Primary Risk Primary PreventionPrevention
Self Self ––Management Management
Complex coComplex co--morbidity morbidity –– 33--5% of LTC5% of LTC
Poorly controlled single Poorly controlled single condition condition –– 1515--20% of LTC20% of LTC
At high risk of At high risk of CVDCVD
Moderately well controlled Moderately well controlled ---single condition single condition –– 7070--80% 80%
of LTCof LTC
Intensive Case/ Care Intensive Case/ Care ManagementManagement
Disease/ Care Disease/ Care Management Management
Population Wide Prevention, Health Improvement & Population Wide Prevention, Health Improvement & Health PromotionHealth Promotion
Targeted High Targeted High Risk Primary Risk Primary PreventionPrevention
Self Self ––Management Management
Complex coComplex co--morbidity morbidity –– 33--5% of LTC5% of LTC
Poorly controlled single Poorly controlled single condition condition –– 1515--20% of LTC20% of LTC
At high risk of At high risk of CVDCVD
33
22
11
00
Level
Level
Level
The
aim
is to
del
ay th
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set a
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low
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prog
ress
ion
and
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dis
ease The Extent and Aim of
Anticipatory Care
Scottish Government and LTCAS
• Strengthen role of voluntary sector
• Strategic Partnership
• Self Management Fund
• SG advised by LTCAS through representation on numerous groups
People are already self managing
But how well are we doing it?• 85% of clinicians believe they share decisions
with patients - 50% of patients believe that this is the case (Healthcare Commission and Picker)
• 60% of primary care clinicians do not endorse patients making independent judgments or acting as independent information seekers (Hibbard and Collins, 2008)
• 33% of people visiting GPs not as involved as much as they wanted to be in decision making (Healthcare Commission)
• 1 in 10 people in survey would ask Dr for clarification
• 20% not aware of treatment optionsHow Engaged are people in their Health Care? Ellins and Coulter, Picker 2005
15 min per month
= 3 hours per year
Copyright 2004 FreePhotosBank.com
Co morbidity – more than one long term condition (PTI practices, ISD)
Co-morbidity
Health conversation as marker of quality
Health conversations
• Each contact is a distillation of attitudes, empathy, experience, education, safety, service design, technology, systems working and management of resources.
• This is where self management begins, it is simply helping people to help themselves – making people aware of sources of support
The inner circle- the health conversation
• CARE measure and Approach
• Health Literacy
• Encouraging use of Teach Back
The inner circleCARE measure
• Consultation and Relational Empathy measure• Developed by Prof Stewart Mercer, funded by CSO grant• Questionnaire – 10 questions given to people after consultation• Feedback tool for staff
CARE measure How was the doctor at……
1. Making you feel at ease2. Letting you tell your “story”3. Really listening 4. Being interested in you as a whole person …5. Fully understanding your concerns
6. Showing care and compassion
7 . Being Positive8. Explaining things
clearly9. Helping you to take
control10. Making a plan of
action with you
The inner circle - the CARE Approach
Connect– Making you feel at ease, letting you tell your story
Assess– Really listening, Being interested in you as a whole-
person– Fully understanding your concerns
• Respond– Showing care and compassion, Being positive,
Explaining things clearly • Empower
– Helping you take control, Making a plan of action with you
The inner circle - Health LiteracyHealth literacy is stronger predictor of health status than
–income–employment status–education level–race or ethnic group
Report on the Council of Scientific Affairs, Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs, American Medical Association, JAMA, Feb 10, 1999
Why health literacy?
• Vital to consider literacy when developing programmes on access to health information
• 23% of adults in Scotland may have low skills1
• People with poor literacy skills have poorer health status, less knowledge of self management and health promoting behaviours
• If right for this group, will be right for all1 Adult Literacy and Numeracy in Scotland (ALNIS), Scottish Executive 2001
• “Medical authors have generally written in a foreign language; and those who were unequal to the task, have even valued themselves upon couching .. their prescriptions, in terms and characters unintelligible to the rest of mankind …Disguising medicine not only retards its improvement as a science, but exposes the profession to ridicule, and is injurious to the true interests of society… The cure of disease is doubtless a matter of great importance; but the preservation of health is of still greater … It is not to be supposed that men can be sufficiently upon their guard against diseases, who are totally ignorant of their causes.”
William Buchan “Domestic Medicine; or a Treatise on the prevention and cure of diseases by regimen and simple medicines” , Chamberlain, 9th ed Dublin 1784
William Buchan 1784
I can read it, but I don’t understand it ..
26.7 per cent may face occasional
challenges Scottish Survey of Adult Literacy, Scottish Govt August 2010
http://www.flickr.com/photos/pchweat/2331900663/
The inner circle - Teach Back
‘To be sure I’ve explained this consent form clearly, can you tell me what you are agreeing to?’’‘I want to check what we’ve discussed – can you tell me what you will tell you partner when you get home?
If information is not restated correctly, then explain again using different words, draw a diagram / simplify instructions, then use Teach back again
The outer circle Assets in Communities
• Boys Brigade
• ALISS and Trinity Academy School
• Patient Portal (Ayrshire and Arran)
• ALISS project
• Links Project
The outer circle – Boys Brigade
The outer circle - Trinity Academy
Patient PortalALISSAccess to Local Information to Support Self Management
The outer circle - ALISS workshops
• 3 workshops – Perth, Glasgow and Edinburgh
• People with long term conditions, service designers and technical experts get together to contribute ideas for improvement
Information to support self management
• NHS Inform - quality assured health information
• ALISS Access to Local Information to Support Self
Management –, citizens informing and supporting each other. Innovative project which will encourage people to create content for local resources
Key Themes from workshops
• Social isolation, loneliness• What happens post diagnosis?• Coping with everyday life• People as information hubs• Hard to find online and offline resources
Key Themes - workshops contd
• Timing of getting information
• We all communicate in different ways
• People don’t like moaning
• Support is often not condition specific (eg emotional and psychological support)
• Support is there but you don’t find it
The outer circle - Links Project
How do primary care teams connect with communities they serve?
• Signposting people to sources of support (aka social prescribing)
• ALISS Access to Local Information to Support Self Management
• Deep End initiative
The outer circle - Links Project
Information being collected in Links
• Teams feedback on current knowledge Identifying local needs (eg mental health, employment, addiction …..)
• what resources teams were aware of, used, trusted
• Learn how primary care teams and people find, understand and use local resources
• Improve connections between primary care and local communities
• Identify processes - training/time/skills required
• Report back on key learning points
Aim of Links
Method
• Short time scale – test out idea
• 6 primary care practices in Glasgow – all in deprived areas
• 4 from Fife – mix of populations
• Data collection supported by LTCC
• Clinical lead for each group
63
64
The outer circle - Patient Portal
• A self management tool• Support people to manage their personal health information eg keep track of exercise, weight, blood results, mood
• Co-designed by people living with LTC
• Place to record clinical health info
65
More info (on resource sheet)
www.aliss.org
ALISS Open Innovation Process(see 6 ideas and materials used)
http://alissproject.wordpress.com/