Personalising Care

Personalised care planning

IMPRESS is preparing more information for this webpage, but until it does, the most important message is that clinicians and patients should think of personalised care planning rather than personalised care plans: that is, as an action rather than a "thing"; clinician and patient planning together rather than producing a document is what matters.

There are some inspiring photographs about the power of personalised care shown here

Background

For background, see (January 2009) Supporting People With Long Term Conditions: Commissioning Personalised Care Planning, issued to help NHS and social care to achieve the goal that by 2010 every one of the 15 million people with a long term condition will be offered a personalised care plan.

Self care

This identifies 5 areas of self care:

Information prescriptions: not tested in COPD yet, but written asthma action plans have well-documented effectiveness
Skills and knowledge training eg EPP or condition specific: Pulmonary rehabilitation is an effective intervention and needs to be made available to all those for whom it would be impactful. Also Expert Patient programmes for asthma.
Tools and monitoring devices including assistive technology: COPD self-management plans have a cautious endorsement from the most recent Cochrane review.
Healthy lifestyle eg smoking cessation: The most important risk factor for COPD is smoking, followed by other aspects of social deprivation, diet and occupational exposure to dust, indoor pollution such as smoke from wood and coal fires, and, in a small number of cases, inherited faulty genes. So, prioritise smoking cessation and dietetic advice for those with low and high BMIs. Smoking stops certain asthma medications working and smoke can trigger asthma symptoms so smoking cessation programmes are a priority. These should include strategies to reduce maternal smoking
Support networks eg Breathe Easy Groups and Asthma UK helpline.

Useful resources
Two SHAs have useful information and resources:

South West

East of England

For a presentation by Tracy Morton, Long Term Conditions Programme, Department of Health, click here.

In North West SHA, there are a number of self care pilots

How should the personalised care plan be recorded and how does it relate to an asthma or COPD action plan? The current view is that the important thing for clinicians to record is that a personal care/health plan exists – and how it can be accessed 24/7 (if it is web based for example). In essence the COPD Action Plan is part of the personalised care plan, which deals with the whole person, not just the condition.

Some organisations are exploring how a personalised care plan could be linked to the Summary Care Record so that it is available (with the individual’s permission) to all relevant clinicians.

There are many other useful resources:

There are COPD Co-creating health pilots in Cambridge and Ayrshire , supported by the Health Foundation. For an overview, see the webcasts from the 2009 IMPRESS conference. For further information on this and the thinking behind co-creation, please use this link here

Co-creating Health self-management for patients video August 2009
Co-creating Health Advanced development programme for clinicians video August 2009
C-creating Health Service Improvement Programme video August 2009

The Picker Institute leads the work on the annual patient experience of the NHS survey.
The Picker surveys have identified 8 key aspects of health care that patients consider most important.
    1.    Fast access to reliable health advice
    2.    Effective treatment delivered by trusted professionals
    3.    Involvement in decisions and respect for preferences
    4.    Clear comprehensible information and support for self-care
    5.    Attention to physical and environmental needs
    6.    Emotional support, empathy and respect
    7.    Involvement of and support for family and carers
    8.    Continuity of care and smooth transition

It also has very useful resources including a review of the evidence on Patient-centred professionalism.

The Year of Care model from Durham University that has focused on diabetes and is now led by NHS Diabetes with Diabetes UK. The concept is to scale up from individual needs – micro-commissioning - in a year of care to a macro commissioning level. See videos, and a consultation script here. This "generic choice model" is promoted by the Department of Health in England.

NHS Evidence on quality and productivity gives an example of success in the care of people with diabetes:
Summary: Personalised care plans have been successful in diabetes. They could be used for other patients with long term conditions. Quality may be improved by better communication, understanding, improved clinical outcomes, and reduced error. Productivity may be improved by increasing compliance with treatment and reduced need for unplanned admissions. Publisher NHS North East.

Partners in Care - A guide to implementing a care planning approach to diabetes care. This considers how to reflect on healthcare professionals' competence and attitudes to co-creating health, describes a care planning approach and the Year of Care model, and pushes the bar pretty high for respiratory care. “We don’t need to agonise over how best to empower people, we just need to stop disempowering them” click here.

NHS Evidence on Self care support for people with long term conditions
Summary: Providing patients with long term conditions better information about their disease, choices for treatment, care pathways, and promoting self care are hallmarks of high quality care. Productivity may be improved if long term conditions are better managed through self care and this results in decreased medical consultation and hospital attendance.

A new Oxford-led review published May 2010 in the Cochrane Library - a gold-standard source for the best evidence-based medical care - showed how empowering people at risk of blood clots to determine their own dose of anti-clotting drugs leads to a large drop in adverse events and deaths. The authors found a 50 per cent drop in the number of blood clots and a 36 per cent reduction in deaths among those patients who were able to monitor and deliver their own anti-clotting therapy. However, the review of the literature compared studies with very varied inputs, often without a detailed description of the intervention, so the review does not give much guide to practical action.

Personal budgets (social care)

Helpful report Keeping personal budgets personal: learning from the experiences of older people, people with mental health problems and their carers 2011 here

Personal health budgets – pilot programme

There is a learning network for anyone interested - see weblink.

Of the 70 pilot sites in England, announced 1 December 2009, these 12 PCTs are piloting in COPD:

Barking and Dagenham
Berkshire West
Birmingham East and North & South Birmingham
Camden
Hartlepool and North Tees
Havering
Heywood, Middleton and Rochdale
Medway
Middlesborough and Redcar & Cleveland (exclusively looking at COPD)
North East Essex
Solihull
Stoke-on-Trent

Direct health payments (see also IMPRESS Social Care and Housing Jargon Buster)

There are some useful presentations on the Care Network website.

See also IMPRESS Jargon Buster entries for Your Health Your Way, Personal Care Plans, Self Care and Supported Self Management.

Last updated Nov 2010.