Person centred integrated care is the holy grail that everyone wants, but getting there is proving challenging. Perhaps what’s needed is a clearer vision of what we’re trying to achieve and how we might get there. A new paper from the King’s Fund on the “house of care” aims to provide just that.
The house of care is a metaphor for a proactive coordinated system of care and support for people with long term conditions. Devised to help primary care staff and commissioners reorganise local services to provide better care and support for these people, it represents a radical departure from the current focus on individual diseases towards a more generic approach in which patients’ goals drive care delivery.
‘People with long term conditions are encouraged to play an active part in determining their own care’
Personalised care planning is at the centre of the house, the fulcrum of a coordinated delivery system. People with long term conditions are encouraged to play an active part in determining their own care and support needs. In pre-arranged appointments they engage in a collaborative care planning process − identifying priorities, discussing care and support options, agreeing goals they can achieve themselves, and co-producing a single holistic care plan with their care co-ordinator (usually a GP or nurse), regardless of how many long term conditions they have.
The house of care ought to be the centrepiece of every integrated care project, with greater attention paid to the contribution that people make towards managing their own health. Assumptions about the incapacity of individuals lead to disempowerment − undermining their self-care efforts. Health and social care professionals who do things with people rather than to them can achieve so much more. There needs to be a greater focus on this in professional training and in integrated care initiatives.
‘Assumptions about the incapacity of individuals lead to disempowerment ‘
Professionals need to recognise that the personal assets that patients (and their families) bring to the care planning process are as important as the clinical information in the medical record. They must also be aware of the capacity of local community and self-help groups to provide appropriate support. The organisation of general practices should be reoriented − from a reactive system that treats people with long term conditions when they become ill to a proactive approach that co-ordinates care and supports people to stay well.
The need to rethink the delivery of primary care is underscored by the pressures of coping with increasing numbers of people with multiple long term conditions and complex needs. According to the Department of Health, the number of people with three or more long-term conditions will rise from 1.9 million in 2008 to 2.9 million in 2018, requiring about £5bn additional NHS expenditure. It makes no sense to plan and organise care around single conditions if more and more of us have more than one health problem. The current disease focused service that leads to fragmented care for patients simply won’t be able to cope.
‘The current disease focused service that leads to fragmented care for patients simply won’t be able to cope’
Shifting to this new model is not easy but the ideas are beginning to take hold across England. Some 3,000 practitioners in 26 communities have begun to introduce aspects of the house of care model via the Year of Care programme and similar initiatives. There is much enthusiasm for the approach, but still some daunting challenges that must be overcome. These challenges include a national GP contract that encourages a focus on single diseases and clinical processes, inflexible IT systems that don’t include space to record patients’ goals, a lack of agreed metrics to measure progress, and funding mechanisms that get in the way of planning care across service boundaries.
None of these problems is insurmountable though. There are already some great examples of joined up care happening across the country at a local level, but the DH and NHS England could do much to remove the barriers. This, coupled with effective local leadership from clinical commissioning groups, would go a long way towards achieving better support and better outcomes for people with long term conditions.
This article also appears on the King’s Fund blog.