Andy Burnham gets personal with tailored care drive

With the publication last month of the pre-Budget report and the 2010 operating framework, the NHS was left in no doubt of the age of austerity coming its way.

But Andy Burnham, in his five year NHS strategy published at the same time, also put considerable emphasis on the importance of providing more personalised services to improve patient care.

There are still elements of care designed around the provider, not the receiver

The commitment itself is not new, but Mr Burnham has given it fresh political impetus. His pledge to link up to 10 per cent of hospital trust income to patient satisfaction gives it financial underpinning.

However, turning “personalised services” into a practical reality is more complex, and integration of services, often seen as the means to this end, can be controversial and requires different ways of working.

Charities representing people with long term conditions may be best placed to suggest what the NHS should begin doing differently to make personalised care a reality. They say what is required is more collaboration, greater consistency and the protection and development of more community based care.

“It’s about being treated as a human being, rather than as a vehicle for one or more conditions in isolation by different people at different times,” National Voices chief executive Jeremy Taylor says.

According to Sir John Oldham, a GP and one of the new national clinical leads for quality and productivity, more collaboration with patients is essential to improving commissioning as well as care planning and supported self-management.

Listening to patients

Sir John says patient feedback is “the cornerstone” of personalisation, and “a very easy option for clinicians”.

Commissioning must shape services in response, he says, so “you are tailoring the service to what people want”.

“There are still elements of healthcare that are designed around the provider rather than the receiver,” he says, and managers “need to get away from that”.

“Unless you understand what your patients think then you’re designing the system around what you think they think.”

Mr Taylor says managers need to be talking to “the right people” at a local level: local authorities, GPs, voluntary sector organisations and condition-specific groups.

“It’s not easy. Commissioners often don’t know where to go, and there isn’t a single group of people that represents all patients. But reaching out has got to be the starting point”.

But managers do not have to start from scratch, NHS Alliance commissioning network director Claire Old says. It is possible to build on practices already in place. “The progressive PCTs are working as close as possible to their local authorities in redesigning services around the personalisation agenda. It’s about doing what we’re already doing, but doing it better.”

For charities representing sufferers of long term conditions, collaboration with patients is just as vital for the provision of services.

Diabetes UK policy manager Gavin Terry emphasises the importance of supported self-management and care planning in a personalised health service. “It’s all very well saying people need to self-manage, but they need to have the support to do that,” he says. Alongside improved education about diabetes and access to dieticians, “a collaborative approach to care” for Mr Terry is one where the professional’s opinion must be “seen as equal” to that of the patient. In practice, this means test results must be sent to patients before a consultation. That frees time to discuss their care plan, in “a marrying of clinical expertise and the person’s own goals”.

Sir John too cites “increasing evidence that if you participate actively in the management of your condition you improve outcomes”.

Macmillan Cancer Support head of healthcare Philippa Palmer believes personal health budgets could help individualise end of life and palliative care, and is working with two health communities to establish pilots. “If you’re thinking about personalisation, the most extreme point is having your own money to spend on what you like to promote what you need. It’s quite an exciting area because it could offer some flexibility and choice for patients and their families and carers. It enables them to take control of their own situation. That’s quite fundamental and important to individuals.”

In order to achieve any meaningful collaboration with patients, clinicians need to provide consistency, according to Picker Institute head of policy and communications Don Redding.

“Personalisation happens in the interaction between a health professional and a patient,” he says. “Their contact with any service is a tiny, tiny window in their lives. The key thing they want is a reliable, known point of contact with the system, who knows about their life circumstances as well as their condition.” This “key liaison” must know about local support services, and proactively keep up with the patient: “Somebody who goes and checks, even by telephone or email”.

That is why Mr Redding believes clinical specialist nurses are “so highly valued” by people with long term conditions. Lung Cancer Forum for Nurses chair Liz Darlison agrees: “Everybody recognises they are the lynchpin of the team.” She suggests that some experienced nurse specialists could take on the role of lead clinicians, moulding services and leading the patient’s cancer journey.

Partners in care

It is this combination of collaboration and consistency, as well as community based care, that brought success to the HSJ Award winning pilot launched by Cardiff and Vale University Local Health Board.

The board’s clinical case managers are experienced nurses based in GP practices who each manage 50 active patients and about 30 others who are contacted less frequently. They proactively seek out people who have a high risk of admission to hospital, assess their physical and social needs, and manage the care package across health, social care, the voluntary sector and other services. Six months into the pilot, average admissions for the eight practices were at approximately 5.1 per week, well below the average of 34.8 per week for the city’s 45 other GP practices.

Strategic lead for chronic conditions management Nicola Hughes says the results stem from clinical case managers being able to “get individuals involved in their care, and listen to what they have to say”. The patient becomes a partner in care, taking ownership of their own health.

For Ms Hughes, the “first step” towards providing more targeted help such as this is moving more services out of the acute sector and into the community. The five year strategy agrees, saying that for it to work, “different professions, services and organisations will need to work together, across traditional boundaries”.

This is where integrated services come into play. But there is too much confusion here, according to Mr Redding, He cites “endless options” given by the NHS for the provision of community services, from PCTs to foundation trusts, from the transformation of community services to the integration of health and social care. “We simply cannot afford that kind of rampant confusion”, he says.

Horizontal integration, which brings health and social care into closer cooperation, appeals to Mr Redding, “because patients certainly don’t want to fall down the cracks in between”.

This is not so for vertical integration, where acute services are more involved in primary and community care. “It is a curious logic that says because the local acute trust is an utterly dominant monopoly which commissioners can’t control, we should therefore give it more power by allowing it to take over primary and community services as well”.

He is “not convinced” that acute trusts are “the right people to provide people-centred, personalised services in the community”.

For the NHS Alliance’s Claire Old, the integration of services facilitates planning across organisational boundaries, but only if care is taken to preserve the “real value” of localised community services.

Technology could provide an economical, effective path to more personalised care. Sir John Oldham cites possibilities including e-counselling, with online behavioural therapy programmes. Validated websites on NHS Choices could enable people to learn about various conditions, “in the same way that we can organise our bank account at any time of day”.

Online medical records would solve the problem experienced by diabetes sufferers, giving all patients access to information to manage their condition more actively. If technology can be harnessed in this way, then the internet could improve personalised services, rather than making them impersonal, at little or no extra cost.

As Liz Darlison puts it: “People are not tins of peas, you can’t process them. You have to look at the person as a whole.”