Health and care professionals are partners in the self care of people who have long term conditions and need ongoing support
There are more than 15 million people in England with a long term condition and this number is expected to double by 2030. The NHS supports people through excellent clinical care every day, but people say they want to do more for themselves - as long as they get the right support.
“Better informed people achieve better health and quality of life,” says Department of Health director of service design Miles Ayling. “They are more confident and better prepared to manage changes in their condition. Supporting people to self care and engaging them in a discussion about their wider holistic needs and aspirations requires a step change in the way frontline staff work with patients.
“This cannot be done without additional support in terms of training, and leadership from within NHS organisations.”
Supporting self care
The importance of engaging people in self care so they can better manage their long term condition is further highlighted by research conducted by national pollsters MORI in 2009. Just over half of those surveyed took an active role in taking care of their condition “all of the time” and, out of these, 56 per cent said they felt very comfortable doing so.
Two thirds of those surveyed had also approached their GP, practice nurse or pharmacist within a six month period seeking self care advice and information.
Government policy to support self care has been developing since the publication of the NHS Plan in 2000, when self care was highlighted as one of the key building blocks for a “patient centred NHS”. This has been followed up with a wider strategy for improving self care support for people with long term conditions, most recently in the form of Your Health, Your Way - a guide to long term conditions and self care.
Record of discussion
Support for self care is an integral part of personalised care planning - a process of involving people in decisions about their health and care through discussion, decision making and ongoing support.
A personalised care plan is a record of the discussion about the support and services available to help someone live with their condition, including agreed decisions, actions, goals and follow-up. There is a government commitment that everyone with a long term condition should be offered a personalised care plan by 2010.
The process of care planning is more than a tick box exercise. It involves a holistic discussion about the person’s full range of needs and wishes, taking into account their health, personal, family, social, economic, educational and cultural circumstances.
After a process of consultation locally NHS East of England has adopted the term personal health planning.
Steve Laitner, the strategic health authority co-chair of the long term conditions programme board, says: “Personal health planning is a supporting process which sees the whole person, not just the ‘LTC’ label, and helps to empower them to take greater ownership and responsibility for their health. Personal health planning supports people to self care and helps them navigate through complex health systems”.
Leaders and managers are responsible to their organisation and their staff for ensuring the highest standards of care are achieved.
Supporting individual empowerment may require staff to work in new and different ways and this needs to be reflected in professional education, induction and continuing professional development. This cannot be done without additional support, and leadership from within NHS organisations.
Manchester health psychologist Christine Bundy suggests there is a lack of training to develop skills in motivating and supporting self care as opposed to traditional skills of education.
She says both types of skills are needed.
“Many people do this work instinctively. However, some struggle to adopt new ways of approaching people with low motivation and poor experiences of support in the past,” says Dr Bundy.
There are a number of recent developments in terms of support for staff including the Common Core Principles to Support Self Care and a Supporting Self Care e-learning package developed jointly between the Department of Health, NHS e-Learning for Healthcare and the Academy of Medical Royal Colleges.
Chair of the academy’s working group David Haslam says that it is important to recognise that supporting people to self care requires a change in the traditional relationship between clinician and patients to become one of “working with”, rather than “doing to”.
“It changes the relationship between the clinician and the individual so it is important for clinicians to understand the context and feel confident that the skills they have are appropriate,” explains Dr Haslam.
The Common Core Principles to Support Self Care are the foundation for the NHS East of England’s Personal Health Planning: a workforce guide to support people with long term conditions.
SHA service development manager Heather Ballard explains that the interactive workforce guide has been developed to help key workers and their managers to understand and develop the skills, knowledge and behaviours required to implement personal health planning.
“Our interactive workforce guide describes three key models; an outline of what the ‘PHP journey’ may look like for an individual with a long term condition, the competencies required of a key worker to support an individual through this journey and a six step guide to identify and develop key workers’ personal health planning skills,” says Ms Ballard.
“We have also produced a range of learning materials which can be used as practical bite sized modules as part of an individual’s development plan or as part of wider team development sessions.”
NHS West Midlands has taken a different approach to training staff for self and personalised care planning with two initiatives aimed at the workforce.
The SHA’s “e-learning interprofessional programme” delivered by Coventry University in collaboration with Warwick Medical School is almost entirely online and covers 12 main areas during a 12 week programme. The SHA plans to roll out the programme to staff across the region later this year.
The SHA is also seeking further workforce development of telehealth care technology to address the skills and competencies the workforce needs to support the use of telehealth care technology with people with long term conditions.
SHA director of nursing and workforce Peter Blythin says: “This area of work will transform future education on the use of telehealth care technology. Patients, many of whom have restricted mobility, will receive more proactive support and advice to help preserve their health and wellbeing.”
NHS Employers is working with the DH to develop an e-learning package for NHS staff to help them understand and apply the principles of personalised care planning in their daily practice.
Jayne Thomas, project manager for the programme at NHS Employers, says: “What should happen is that people with long term conditions are able to have a conversation about their condition and how it is impacting on the things that are important to them.
“They should be able to discuss the range of support available, the extent to which they are able to self care, what support groups are available and the most convenient way for them to access further information. This additional tool and resource for staff will enable them to work more effectively with patients in a care planning discussion.”
Resources outside the NHS
There are other initiatives designed to support staff in working differently. The Health Foundation has invested over £6m in a three year, large scale demonstration programme called Co-creating Health. This takes a whole system approach and aims to embed self-management support within mainstream health services.
As part of the project, clinicians across the UK are undertaking a nine-month advanced development programme to improve their self-management support and communication skills.
Alongside this, people with long term conditions are participating in a seven-week self-management programme to build their skills, knowledge and confidence to self manage. As a result of the collaboration between clinicians and patients, the eight Co-creating Health sites are improving the way their health services are designed and operated.
If patients are better informed, and staff are better able to support people to self care, then the health service needs to adopt systems and processes and a culture that will embrace this.
NHS staff need to feel supported by their own organisation to work in different ways, not just in terms of structure and practice, but in terms of their personal health and motivation.
The forthcoming NHS health and wellbeing review will help focus NHS organisations on the fitness of their staff.
Initial findings from the review show that having healthier staff who are not under undue stress and teams that are not disrupted by sickness all contribute to the quality of care and also patient satisfaction.
To support commissioners the NHS South West Development Centre has developed a resource pack that brings together examples of self care information and policy documents so that primary care trusts can develop local self care policies.
The DH is also establishing a new PCT support programme from 2010 to support implementation of DH commitments such as the offer of a personalised care plan to everyone with a long term condition by 2010 and better access to timely, relevant and accredited information through information prescriptions.
It will be a large scale facilitated programme, which engages with health and social care organisations to identify their support needs and works collaboratively with commissioners to develop local implementation solutions.
National director of primary care David Colin-Thomé says: “Effective support for self care and care planning needs co-operation between all parties concerned - health, social care and local authorities working with community, voluntary and private sectors to provide local solutions to embed supported self care as a practical option.
“But at the heart of this support is a trusting relationship between the person and the professional.
“NHS organisations need to take steps to create an environment which will support managers to support staff to support patients in enjoying improved clinical outcomes and better quality of life.”
Case study: NHS East of England
There are an estimated 1.6 million people in the East of England with a long term condition.
Of these, 59 per cent report that they have a long term illness, health problem or disability which limits daily activity or work. With an ageing population, it is estimated that by 2025 there will be 47 per cent more people in East of England aged 65 or over. This will mean that the number of people with at least one long term condition will rise by 300,000 to 850,000.
NHS East of England’s vision is ambitious. All primary care trusts will be required to offer personal health plans to two long term condition patient groups by March 2010, a further three groups by September 2010 and to all long term condition patient groups by December 2010.
The strategic health authority, along with individuals with these conditions, their carers, health and social care colleagues and representatives from the third sector, have worked over the past 18 months to understand the best way to implement personal health planning - the name was chosen because of its collaborative approach.
The SHA hopes personal health planning will empower individuals to take greater ownership and responsibility for their care and the management of their condition: it advocates an empowered and less paternalistic approach.
An enabling tool
The process starts with an understanding of the principles.
These have been described as part of the “PHP journey”, which includes the preparation of supporting an individual to understand what personal health plans may mean for them, supporting individuals to create a plan and enabling them to live with the plan through realising personal goals.
The personal health plan is a tool, which records the outcomes from the planning session between the individual and their key worker.
The plan is owned by the individual and contains all the information an individual needs to manage their own care.
In March 2009 NHS East of England began a pilot across 15 sites to test the personal health plan tool and to start to explore key components of a workforce guide.
Findings from the pilot sites showed that the SHA needed to review the personal health plan tool, develop a communications plan and stakeholder engagement strategy, and identify staff capability and align this to current workforce systems.
In October, NHS East of England launched a series of tools and resources to support organisations, teams and key workers to implement the initiative.
NHS East of England, in partnership with Capgemini, developed a regional workforce guide Understanding Personal Health Planning: a workforce guide to support people with long term conditions.
The interactive guide consists of three key components; PHP Journey, PHP Competencies and a Six Step Guide to Developing your PHP Skills.
NHS East of England has also developed a Six Step Guide to assessing personal health planning skills for staff.
The guide helps key workers and their managers to:
- Identify and familiarise themselves with the personal health planning competency domains
- Identify their personal health planning competency development areas through self assessment
- Incorporate personal health planning objectives into a development plan and identify key learning materials
- Develop a portfolio of evidence to illustrate competence
- Align personal health planning objectives with performance development reviews
- Meet requirements of regulatory bodies and clinical governance.
Implementation of the tools and resources began this October and will continue through to March 2010 via a series of county based workshops, as well as online support through a regional virtual network.
|Traditional interactions||Collaborative interactions|
|Information and skills are taught, based on the clinician’s agenda||Patient and clinician share their agendas and collaboratively|
decide what information and
skills are taught
|There is a belief that knowledge creates behaviour change||There is a belief that one’s confidence in the ability to change (“self-efficacy”), together with knowledge, creates behaviour change|
|The patient believes it is the clinician’s role to improve health||The patient believes that they have an active role to play in changing their own behaviours to improve their own health|
|Goals are set by the clinician and success is measured by compliance with them||The patient is supported by the clinician in defining their own goals. Success is measured by an ability to attain those goals|
|Decisions are made by the clinician||Decisions are made as a patient-clinician partnership|