Organisational Journey

Supporting self-managementfor people living with long-term

conditionsconditions

Organisational Journey

http://personcentredcare.health.org.uk

Our Journeys

2005 -2007

Pre-CCHSelf Mgt

Work- streams/ strategy

EPP

Health Trainers

2007-2010- Co-Creating Health 1Developing p’ships

Year of Care

Implementing SMPs & ADP

2010-2012

Co-Creating Health 2Sustainability & Spread

Commissioning/ 3rd Sector : NESTA

2013-2015

Continuing SMSSynergies with local strategic drivers

Embedding

Good practice

Self Mgt Support Networks

More Development of P-ship Models

2015-

Next StepsDevelopment of

Clinical Strategies

Development of Strategies to work with Education Providers (more widely)

Building Capacity

Continuing with culture change

Commissioning

http://personcentredcare.health.org.uk

Backdrop to our journeys• Change in NHS – Organisational and

Commissioning• Policy Change – Recognition of the

importance of developing services to better meet needs of people living with long-term conditions

• Integrated Care Models• Better Care Fund 2013• Care Act 2014

http://personcentredcare.health.org.uk

Backdrop to our journeysHouse of Care Model

“More than medicine”Informal and formal sources of support and care sustained by the

responsive allocation of resources

Progress

Transformative – patient and clinician relationship Self-Management Programmes for people living with a

variety of long-term health conditions Self-management support built into delivery models for

patient services Peer Support Groups open to patients following self-

management programmes which meet regularly Collaborative delivery with health-care professional and

lay-facilitators

http://personcentredcare.health.org.uk

Progress

Award winning programmes Inter-professional training offered for all staff and to

support whole staff teams Training delivered to Medical Students and Specialist

Registrars Diversification of training to reach different front line

staff audiences. Eg: GP Receptionists; Pharmacists.

http://personcentredcare.health.org.uk

Progress

Self-Management Support NetworkContribution to national learning through

Co-Creating Health and beyondRecognised as National leaders in the field

http://personcentredcare.health.org.uk

Progress

Enabler of Strategic priorities & development of other services

Ongoing interest from national and local policy makers and commissioners

http://personcentredcare.health.org.uk

Enabler of integrated care

“Self Management Network and self management support work have linked different parts of the organisation that previously have had no obvious connections, and have connected to local authority and voluntary services too!”

“Self management support is increasingly finding its way into peoples’ vocabulary, strategic plans and service objectives”

“This is the first time I have felt like part of an Integrated Care Organisation”

ChallengesLeadership & Supportive infrastructure• Building /resourcing whole-systems approach across

the patch• Developing a common language across the WHOLE

local economy• Outreach to whole workforce at the same time• Clear and consistent approach to supporting self-

management – keeping consistent standards • Cultural shift – time and focus needed – huge

numbers • Whilst all sites have some good strategic leaders and

clinical / managerial leadership – it is not consistent across all parts of the system

Challenges

Engaging Service Users• Patient Power remains under-utilised

Skills /development• Maintaining capacity to deliver programmes• When Teams are to be supported, significant effort and

investment can be required, for example, staff can lack confidence at the beginning of their journey; service specifications may need to change to support self-management; skills need to be practiced

Commissioning• Commissioning and securing future commitment to SMS

Engaged, inform

ed patient

HCP com

mitt

ed to partnership w

orking

Organisational processes

Commissioning – The foundation

Building the house with

ALL providers

Scaling up; building capacity

Must review what is already

being done

Move from disease specific

silos

Didn’t develop outcome

measures at the start

Infrastructures/ IT systems do not support shared care

and support planNHSE care planning template

Fragmented commissioning system/tariffs

Pressure of TIME for good conversations

Annual funding cycle

challenging to providers

Competency framework

patient safety connection

Reinforcing new ways

My job?

Capacity -TIME

Capacity -100’s of clinicians to reach

“I’m already doing this” – “unknown unknown”

Deprivation and low levels of

activation

Peer support and “more than

medicine”

Reaching people

1000’s of people to reach

Key learning themes

• Align and integrate • Engage• Good leadership• Passion, belief and resilience• Work collaboratively• Understand what drives behaviour change

and link to SMS • Resources in the current climate• Networking

http://personcentredcare.health.org.uk

Committed and respectedleadership engaging the staff

A culture hospitable and supportive of change

Data and analytics that measure and communicate impact

Management practices that ensure execution and implementation

An enabling environment which

supports and drives change

Resources and support to do the

work of change

Capabilities and skills to identify

and solve problems

Image from: Constructive comfort: accelerating change in the NHS, The Health Foundation, February 2015http://www.health.org.uk/publications/constructive-comfort-accelerating-change-in-the-nhs/

Practical tools & resources to help clinicians understand and implement Person-centred care

http://personcentredcare.health.org.uk