West Yorkshire and Harrogate Health and Care Partnership Our Journey to Personalised Care

25 February 2019

Housekeeping

Agenda • Welcome & Introductions • Universal Personalised Care (UPC) • West Yorkshire and Harrogate Health and Care Partnership: purpose, vision & why we

need change? CEO Experience And Challenges Of System Working • Break & Marketplace • Workshops session • Lunch & Market Place • A Personal View • The cultures we need to support Universal Personalised Care - The stories of

Collaborative Practice. • Workshop session • Coffee Break & Market Place • Q&A Panel Session • Next Steps • Close and Networking

Hello my name is… Jo Webster, Chief Officer, Wakefield Clinical

Commissioning Group & Lead for Personalised Care

https://www.youtube.com/watch?v=Zw8A_O6R5lo

SMaSH groups in Wakefield – Self-Management and Self-Help

Hello my name is… James Sanderson, Director of Personalised Care,

NHS England &

Pritti Mehta, Head of Personalised Care, North Region, NHS England

www.england.nhs.uk

Universal Personalised Care: Implementing the Comprehensive Model

February 2019

Comprehensive Model for Personalised Care All age, whole population approach to Personalised Care

People with long term physical

and mental health conditions

30%

People with

complex needs

5%

Supporting people to stay well and building community resilience,

enabling people to make informed decisions and choices when their

health changes.

Supporting people to build knowledge, skills

and confidence and to live well with their health

conditions.

Empowering people, integrating care and reducing unplanned

service use.

Specialist Integrated Personal Commissioning, including

proactive case finding, and personalised care and support planning through multidisciplinary teams,

personal health budgets and integrated personal budgets.

Targeted Proactive case finding and personalised care and

support planning through General Practice. Support to self manage by increasing

patient activation through access to health coaching, peer support and self management education.

Universal Shared Decision Making.

Enabling choice (e.g. in maternity, elective and end of life care).

Social prescribing and link worker roles. Community-based support.

Plus Universal and Targeted interventions

Plus Universal interventions

Whole population 100%

INTERVENTIONS OUTCOMES

TARGET POPULATIONS

www.england.nhs.uk

• 86% of people said they achieved what they wanted with their PHB. 77% of people would recommend PHBs to others with similar needs.

• Independent reviews have found evidence that people’s well-being, satisfaction and experience improves through good personalised care and support planning, including for people with cancer.

• 75% of people who booked hospital outpatient appointments online felt they were able to make choices which met their needs.

• People and professionals consistently overestimate treatment benefits and underestimate harms. Shared decision making helps reduce uptake of high-risk, high-cost interventions by up to 20%.

• Local evaluations of social prescribing have reported improvements in quality of life and emotional wellbeing, as well as lower use of primary care and other NHS services. Systematic reviews have found that the quality of evidence is variable and there is a need for more evidence on the effectiveness of social prescribing.

• Personalised care and support planning has been shown to improve GP and other professionals’ job satisfaction.

• Monitoring of costs for PHB holders receiving NHS CHC home care packages found an average saving of 17%.

• An independent evaluation found that PHBs were overall cost neutral. People with a PHB had lower indirect costs through less use of secondary healthcare (average £1,320 per person per year).

• In one site, IPC was implemented at scale alongside other interventions. Following the 100-day challenge in 2017 the site saw a reduction in emergency admissions of 12%, as well as a 24% reduction in A&E attendances for the two practices which took part.

• An independent evaluation found that people who had the highest knowledge, skills and confidence had 19% fewer GP appointments and 38% fewer A&E attendances than those with the lowest levels of activation. This finding was corroborated by a Health Foundation study which tracked 9,000 people across a health and care system.

The difference personalised care makes To people’s experiences

To people’s outcomes

To the workforce experience

To the system

www.england.nhs.uk

Local examples of impact

FYLDE COAST Self-management

STOCKTON Care planning

Patient Activation Measure scores increased

by an average of 8.9% following care and support tailored to

people’s needs 24% reduction in A&E attendances in 2017 within two GP practices

12% reduction in unplanned admissions in 2017 within two GP

practices

NOTTINGHAMSHIRE Personal health budgets

£25,000 saving in transport costs for siblings with very complex health

conditions

Lease their own adapted vehicle through a personal health budget for journeys to day centre and respite,

instead of a commissioned transport package

Health improvements included average 10 point increase in EQ-

VAS scores

BRADFORD Social prescribing

74% of people increased their mental well-being after being referred to the scheme

www.england.nhs.uk

Chapter One sets out a new NHS service model for the 21st century. This will be achieved through the following five major, practical, changes over the next five years: Boost ‘out-of-hospital’ care and dissolve the divide between primary and community services 1. Redesign and reduce pressure on emergency hospital services

2. People will get more control over their own health, and more

personalised care when they need it

3. Digitally-enabled primary and outpatient care will go mainstream across the NHS.

4. Local NHS organisations will increasingly focus on population health and local partnerships with local authority-funded services, through new Integrated Care Systems (ICSs) everywhere

The NHS Long Term Plan

www.england.nhs.uk

What does this entail? • Roll out the Comprehensive Model for Personalised Care across England, reaching 2.5 million people by 2023/24 and

aiming to reach 5 million people by 2028/29 (para 1.39) • Standard models and quality indicators for each component below, ensuring quantity and quality

Component Goal by 2023/24

Shared decision making Shared decision making embedded in 30 high value clinical situations in primary care, secondary care and at the primary/secondary interface where it will have the greatest impact on experience, outcomes and cost

Personalised care and support planning

750,000 people, including people with long term conditions, people at the end of life, and pregnant women

Enabling choice, including legal rights to choice

Legal rights to choice are maintained throughout wider system transformation, with 100% of elective referrals exercising choice through the electronic Referral System and 100% of CCGs compliant with choice improvement guide

Social prescribing and community-based support 900,000 people referred to social prescribing link workers

Supported Self-Management Continue to increase the opportunities for people to benefit from supported self-management approaches

Personal health budgets and integrated personal budgets 200,000 people benefitting from PHBs or IPBs

www.england.nhs.uk

Specific Personalised Care commitments in LTP •Accelerate roll out of Personal Health Budgets… Up to 200,000 people will benefit from a PHB by 2023/24 (para 1.41)

•Over 1,000 trained social prescribing link workers by 2020/21 and 900,000 people referred to social prescribing link workers by 2023/24 (para 1.40)

•Ramp up support for people to self-manage their own health (para 1.38)

•People have choice of options for quick elective care, including choice at point of referral and proactively for people waiting for six months (para 3.109)

•Support and help train staff to have personalised care conversations (para 1.37)

•Use decision-support tools (para 3.106) and ensure the least effective interventions are not routinely performed… potentially avoiding needless harm (para 6.17viii))

30%

5%

100%

www.england.nhs.uk

Other commitments that depend on Personalised Care

• Significant commitments to support care quality and outcomes, including applying the Comprehensive Model of Personalised Care to end of life care (para 1.42), dementia (para 1.20) and cancer (para 3.64)

• Enabling more personalised care and choice and control for people with learning disabilities, autism

or both (para 3.34), children and young people (para 3.47), and people with mental health conditions (para 3.106)

• Personalised care and support planning approaches in maternity (para 3.13), CVD (para 3.70) and to

support people to manage their condition in work (appendix on health and work) • Expand supported self-management for people with long-term conditions (para 2.2), including

diabetes (paras 3.79, 5.13), respiratory disease (para 3.85) and MSK conditions (para 3.107)

• Community pharmacies will also promote and support self-management for people (para 1.10) • In addition to the above, personalised care is:

• Recognised as enabling the shift to digital and vice versa (para 5.8-5.9) • Recognised as a practical enabler of integration (para 1.58) • To be supported and enabled through the revised QOF (para 1.11)

www.england.nhs.uk

Personalised care and other programmes

Digital ⇄ Personalised Care Personalised Care and Digital complement each other in delivering modern healthcare approaches

Who: People with complex needs We will empower people, integrate care and reduce unplanned service use.

Who: People with long term physical and mental health conditions We will support people to build knowledge, skills and confidence to live well with their conditions.

Who: Whole population We will support people to stay well and enable them to make informed decisions and choices when their health changes.

• Digital health and care plans • Personal Health Budget tools to

help resource allocation, e.g. e-marketplace

• Personal Health Records to ensure better coordinated care

• Online education and treatment e.g. digital IAPT

• Digital Patient Activation Measurement

• Directory of services to support social prescribing

• Staying well, making informed choices to help the access the right care, at the right time through digital means, including the NHS website, NHS App and other health apps.

Spec

ialis

t Ta

rget

ed

Uni

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al

Using assistive technology, Maggie can review and amend her care plan at a time and place that’s right for her; knowing that every care professional that supports her has access to it. It also means every clinician can see her care preferences.

Gary found it hard to accept that he had Type 2 diabetes. Using the patient activation measurement tool has helped him access more relevant support to build his knowledge, skills and confidence, and via the NHS Apps Library he can now use his phone to monitor his diet.

Pardeep has recently been diagnosed with a serious medical illness, which may require an operation. By accessing the NHS.uk website, he found out about the risks and benefits of the surgery, before choosing whether to proceed.

5%

30%

100%

Digital enablers This means… Personalised care enablers

Personalised care and support planning provides the standards required to support people to have access to both read and edit their Personal Health Records, which will be achieved through the NHS app

Shared decision making establishes the expectation that people are equal decision makers with clinicians, helping shape content on the NHS website

Supported self-management means increasing people's knowledge, skills and confidence (patient activation). By increasing “activation”, people can better make use of the entire suite of digital first options that Empower the Person is delivering

25 January 2019

www.england.nhs.uk

How will we deliver this? Universal Personalised Care is the delivery plan for personalised care, and sets out 21 detailed actions to achieve the systematic implementation of the Comprehensive Model for Personalised Care. These actions are summarised below

Communications, partnerships and

co-production

• Publish Comprehensive Model with standard models

• Behaviour and culture change campaign

• Support people with lived experience to be system leaders and build demand

Skills, behavior and culture change

• Training and support for clinicians and professionals

• Embed personalised care in pre- / post-education training

• Embed shared decision making into specific clinical situations

Local implementation

• Deliver Comprehensive Model in ICS, STP and PCNs

• 3 Integration accelerators

• Effective mechanisms to enable choice and control

• Implement supported self-management approaches

• PHB expansion, increasingly by default

Community-based approaches

• Social prescribing link workers in all local areas

• Explore best models for commissioning and supporting voluntary sector

Transition and infrastructure

• NHS Personalised Care

• Digital and personalised care

• Personalised Care dashboard

• Health inequalities

Levers and incentives

• Introduce new legal rights to personalised care

• Embed and use levers and incentives

• Integrate model into wider transformation and frameworks

• Include wider funding streams

Impact and outcomes

• Evidence and impact

• National Impact Statement

Hello my name is… Rob Webster, CEO for South West Yorkshire

Partnership NHS Trust & CEO Lead for WY&H HCP

Purpose, vision & why we need change?

Rob Webster

25 February 2019

#Hello my name is ……..…

Chief Executive of South

West Yorkshire Partnership NHS Foundation Trust

CEO Lead for West Yorkshire and

Harrogate Health and Care Partnership

3

West Yorkshire and Harrogate Health and Care Partnership

23

WY&H Health and Care Partnership – Our Vision

24

In 2018/19 WY&H became a Personalised Care Demonstrator Site and we have made good progress….

Social Prescribing commissioned in all

of our 6 places

Personal Health Budgets available in

all of our 6 places

Patient Activation Measures in place in

4 of our 6 places with 2 places being

mentored

Shared Decision Making trialled in 2

of our 6 places

Personalised Care & Support Planning

fully implemented in 1 of our 6 places, with a further 3

places progressing

Over 100,000 people receiving

‘personalised care’ across WY&H at

Quarter 3 2018-19

25

Where we are making a difference……

Wheelchair PHB mentor (Leeds)

The Better Living Team (Calderdale)

Motivation to Move (Calderdale)

(Leeds)

(Kirklees)

(Bradford)

26

The NHS Long Term Plan

Up to 2.5 million people will benefit from Personalised Care by 2024, giving them the same choice and control over their mental and physical health that they have come to expect in every other aspect of their life.

This includes:

• the expansion of personal health budgets with 200,000 people set to benefit from one in the next five years.

• around 750,000 people with a long term health condition will also receive a written personalised care and support plan to manage their condition.

• up to 900,000 people will benefit from social prescribing and community-based interventions by 2024.

27

What is next …… The commitments in the NHS Long Term Plan fit with our WY&H vision…“putting you at the centre of everything we do”

We will continue to apply this to all of our programmes and in everything we do

28

We are a guest in people’s lives

30

• Visit www.wyhpartnership.co.uk • Weekly blog www.wyhpartnership.co.uk/blog • ‘Our Next Steps’ www.wyhpartnership.co.uk/next-

steps • Follow: @wyhpartnership @NHS_RobW

Further information

31

Coffee break & Market place

Social prescribing workshop David Cowan

Collette Connolly Samantha Monk

33

What is Social Prescribing?

https://youtu.be/O9azfXNcqD8

34

White paper 2006: ‘Our Health, our care, our say’

• Focus is in self-management

• Long-term, chronic conditions

• Direct referral from GPs (e.g. exercise on prescription)

• Focus on information to tackle chronic conditions (Expert Patient Programme)

• Community matrons for complex long-term needs

35

Policy interest in social prescribing

• Model for integration across health and social care systems

• One of the 10 high impact actions to release capacity

• Drive to personalize health and social care

• One of the emerging models (Rotherham)

• It was proven to cut A&E, out-patient and hospital admissions

36

Health Inequalities: A wealth of Epidemiological Data

Marmot Review 2010 ‘Mechanisms like social prescribing show signs of empowering individuals to participate and take control of their health and wellbeing (p.155)’

37

NHS 10 Years Plan: good news… • Greater focus on prevention and £20b additional

funding to NHS

• Link workers will work with service users to develop tailored plans and connect them to local groups and support services.

• 1,000 additional trained LWs to in placed by 2020/21.

• Final aim 900,000 people will be able to use Social Prescribing by 2023/24

38

• Public health budget has been cut (NHS, 2019), and corresponding investment to social care and voluntary sector has not increased.

• Who are service users going to be referred to if VCSE is in difficulties?

• Will Local Authorities be able to fund SP if public health

budgets are declining?

• Issues around how Primary Care Networks may commission this

NHS 10 Years Plan: some potential issues…

39

SOCIAL PRESCRIBING AS SIGNPOSTING • Online access to community activities • Direct signpost from GP practice • Emerging evidence base • Leaflet in the GP practice • No link worker SOCIAL PRESCRIBING LIGHT • Run by the voluntary sector to refer people to other activities

delivered by the voluntary sector • To address a specific need of vulnerable patients • No direct links with GP practices

Models of social prescribing (Kimberlee, 2015)

40

SOCIAL PRESCRIBING MEDIUM • Link worker or advanced care navigator • Health focused (nutrition, diet, CBT) • Signpost to voluntary sector and/or self-help groups • Not focused on beneficiary needs in a holistic way SOCIAL PRESCRIBING HOLISTIC • Direct primary care referral to SP provider • SP provider is local and employs link workers • Link worker follows a ‘holistic’ approach (centred

on person’s needs) • No limits on number of sessions. These depend on

person’s need

Models of social prescribing (Kimberlee, 2015)

41

Key elements of Social Prescribing

42

The Bradford story

43

• VCS Summit 2016 • Secured non-recurrent funding (Jan – Dec 17)

• Local Authority contribution

• Commissioning proposal

1. Experience of delivering in Bradford 2. Partnership bids 3. Excellent knowledge of the community and VCS

• Pilot in 26 practices with extensive evaluation

• Collaborative relationship between commissioner/provider

• Secured further investment (Jan 18 – Mar 20)

Commissioning the service

44

45

46

Key Ingredients of Social Prescribing

Taken from: REPORT OF THE ANNUAL SOCIAL PRESCRIBING NETWORK CONFERENCE Wednesday 20 January 2016

47

• Referral pathway – GP’s / Practice staff

• Referral guidelines

• Practices/ Community Partnerships

• SystmOne

• Staff team / Partners

• Training: MHFA / conversations 4 change/ MI

• Regular communication/ peer support/ whats app

• A&E – referral pathway

Hale Community Connectors model

48

• 2017 pilot – 703 referrals - 26 pilot practices

• 2018 a total of 1133 referrals were received for Community Connector support.

• 35 district and 25 city practices

• The service is available to all patients who fit criteria • Out of 162 referrals explored during the pilot, service users were

referred onto 100+ different groups and organisations.

Numbers

49

Better quality of life

Improved individual health and wellbeing outcomes

Improvements in mental wellbeing

Reduced levels of social isolation and loneliness

Improved health behaviours

Improvements in confidence levels, self-esteem and ability to self-care

Better use of Third Sector services

Improved access to non-medical social activities and support

Reduced healthcare resources

Reduced demand on GP services

Reduced demand on urgent care and secondary care services

Improved patient experience

Outcomes

50

• Sheffield Hallam pilot evaluation/ Embed 6 month report

• Most recent evaluation highlights: – Overall, notably more women than men are using the service. – an even distribution of age groups. – Ethnicities of the service users are fairly represented in line with

the 2011 Census

• Five Key measures: Mental wellbeing , Trust, Social Connectedness, Self Care and Satisfaction results all very positive

• The most notable impact was on GP Appointments which saw a reduction of 14%

Evaluation/Impact

51

52

• Funding • Community partnerships • CEE focus • A & E • Ongoing development/ supporting new groups were gaps

identified • Linking in with other Social Prescribing services – sharing good

practice.

New developments

53

•Mrs S had attempted suicide several times and was awaiting a bed to be hospitalised for her mental ill health. •After a short intervention with a community connector Mrs S had met up with people in her local community who she had connected with/ exchanged numbers. She had engaged with the Community Connector and begun to focus on the positive aspects of her life •Mrs S made the decision to remain in her own home, deciding she no longer required this level of intervention. •The Community Connector supported her to access local mental health support in the community. •Mrs S has gone from strength to strength .

84 year old Mrs R had missed many appointments and was struggling. She had become very anxious and nervous She struggled to speak English She also required urgent cataract surgery. • Speaking her own language our Community Connector was able to help her navigate the vast amount of confusing missed/ re-arranged appointments, including her important surgery. She was supported to understand what help was available for her locally to help translate. During the intervention Mrs R had further underlying health needs which she was supported to address promptly. A broken boiler and carbon monoxide testing were also identified and addressed with help.

Please visit the market stall for further details and a vast array of case studies/ newsletter

Stories

54

• Widen referral routes – social care, self referral, group work, link with ABCD funding, community partnerships

• Secure recurrent funding • Refining the evaluation process

• Integrated Care System – more joint work/learning

• Living well programme – align to wellbeing services

• Joint CCG/Local Authority approach

• Personalised care programme – clear linkages

• Evergreen – digital social prescribing

Developing the service

55

• Questions • Opportunities • Sharing learning from other ICS areas

David Cowan

collette.connolly@bradford.nhs.uk Samantha Monk

Questions/group chat

56

1. What can we do together across WY&H? 2. What can we do individually? 3. How do we embed personalised care in our work?

So…

57 57

Lunch & Market Place

Hello my name is… Diane Burke, Head of Public Health – (Long Term

Conditions)-Leeds City Council &

Geoffrey Thorne, Group Secretary Breathe Easy Bramley

www.england.nhs.uk

Matt Simpson and Gill Goodwin Personalised Care Group, NHSE

Personalised Care and Support Planning

Comprehensive Model for Personalised Care All age, whole population approach to Personalised Care

People with long term physical

and mental health conditions

30%

People with

complex needs

5%

Supporting people to stay well and building community resilience,

enabling people to make informed decisions and choices when their

health changes.

Supporting people to build knowledge, skills

and confidence and to live well with their health

conditions.

Empowering people, integrating care and reducing unplanned

service use.

Specialist Integrated Personal Commissioning, including

proactive case finding, and personalised care and support planning through multidisciplinary teams,

personal health budgets and integrated personal budgets.

Targeted Proactive case finding and personalised care and

support planning through General Practice. Support to self manage by increasing

patient activation through access to health coaching, peer support and self management education.

Universal Shared Decision Making.

Enabling choice (e.g. in maternity, elective and end of life care).

Social prescribing and link worker roles. Community-based support.

Plus Universal and Targeted interventions

Plus Universal interventions

Whole population 100%

INTERVENTIONS OUTCOMES

TARGET POPULATIONS

Shared decision making

Social prescribing & community-based support

In 2017/18 SDM was embedded into: • Musculoskeletal elective care

pathways across 13 CCGs • Respiratory elective care pathways in

8 CCGs

• 68,977 referrals in 2017/18 • 331 link workers employed in

local areas

Personalised care and support planning

• 142,904 people had a personalised care and support plan between April 2017 and September 2018

• Over 204,000 people supported by integrated, personalised approaches

Supported self management

Enabling choice

• 97% of CCGs have now completed Choice Planning and Improvement self-assessment

• Of these, 85% report compliance with at least 5 (of 9) choice standards

• 32,341 PHBs by September 2018 • Up 110% year-on -year in 2018 (to end

Q2) • 23% jointly funded with social care • 55,511 Personal Maternity Care Budgets

delivered by September 2018 across 36 CCGs

Personal health budgets & integrated personal budgets

• 101,637 patient activation assessments by September 2018

• Over 44,093 people referred to community-based support

• Over 59,545 people referred to self-management education or health coaching

Significant delivery of Personalised Care

• 86% of people said they achieved what they wanted with their PHB. 77% of people would recommend PHBs to others with similar needs.

• Independent reviews have found evidence that people’s well-being, satisfaction and experience improves through good personalised care and support planning, including for people with cancer.

• 75% of people who booked hospital outpatient appointments online felt they were able to make choices which met their needs.

• People and professionals consistently overestimate treatment benefits and underestimate harms. Shared decision making helps reduce uptake of high-risk, high-cost interventions by up to 20%.

• Local evaluations of social prescribing have reported improvements in quality of life and emotional wellbeing, as well as lower use of primary care and other NHS services. Systematic reviews have found that the quality of evidence is variable and there is a need for more evidence on the effectiveness of social prescribing.

• Personalised care and support planning has been shown to improve GP and other professionals’ job satisfaction.

• Monitoring of costs for PHB holders receiving NHS CHC home care packages found an average saving of 17%.

• An independent evaluation found that PHBs were overall cost neutral. People with a PHB had lower indirect costs through less use of secondary healthcare (average £1,320 per person per year).

• In one site, IPC was implemented at scale alongside other interventions. Following the 100-day challenge in 2017 the site saw a reduction in emergency admissions of 12%, as well as a 24% reduction in A&E attendances for the two practices which took part.

• An independent evaluation found that people who had the highest knowledge, skills and confidence had 19% fewer GP appointments and 38% fewer A&E attendances than those with the lowest levels of activation. This finding was corroborated by a Health Foundation study which tracked 9,000 people across a health and care system.

The difference personalised care makes

To people’s experiences

To people’s outcomes

To the workforce experience

To the system

Emerging evidence

FYLDE COAST Self-management

STOCKTON Care planning

Patient Activation Measure scores increased

by an average of 8.9% following care and support tailored to

people’s needs 24% reduction in

A&E attendances in 2017 within two GP practices

12% reduction in unplanned admissions in

2017 within two GP practices

Across Continuing Health Care, direct savings of up to 17%

NOTTINGHAMSHIRE Personal health budgets

£25,000 saving in transport costs for siblings with very complex health

conditions Lease their own adapted

vehicle through a personal health budget for journeys to day centre and respite,

instead of a commissioned transport package

www.england.nhs.uk

Health improvements included average 10 point increase in EQ-VAS scores

BRADFORD Social prescribing

74% of people increased their mental well-being

after being referred to the scheme

Personal health budgets

Chapter One sets out how the NHS will move to a new service model in which the NHS will increasingly be: more joined-up and coordinated in its care; more proactive in the services it provides; more differentiated in its support offer to individuals.

It sets out five major, practical, changes to the NHS service model to bring this about over the next five years: • 1. We will boost ‘out-of-hospital’ care, and finally dissolve the historic divide

between primary and community health services. • 2. The NHS will redesign and reduce pressure on emergency hospital services. • 3. People will get more control over their own health, and more personalised

care when they need it. • 4. Digitally-enabled primary and outpatient care will go mainstream across the

NHS. • 5. Local NHS organisations will increasingly focus on population health and local

partnerships with local authority-funded services, through new Integrated Care Systems (ICSs) everywhere.

65

The NHS Long Term Plan Chapter 1: A new service model for the 21st century

What does this entail?

Roll out the Comprehensive Model for Personalised Care across England, reaching 2.5 million people by 2023/24 and aiming to reach 5 million people by 2028/29 (para 1.39)

Component Goal by 2023/24

Shared decision making Shared decision making embedded in 30 high value clinical situations in primary care, secondary care and at the primary/secondary interface where it will have the greatest impact on experience, outcomes and cost

Personalised care and support planning 750,000 people with long term conditions

Enabling choice, including legal rights to choice Legal rights to choice are maintained throughout wider system transformation, with 100% of elective referrals exercising choice through the electronic Referral System and 100% of CCGs compliant with choice improvement guide

Social prescribing and community-based support

900,000 people referred to social prescribing link workers

Supported Self-Management Continue to increase the opportunities for people to benefit from supported self-management approaches

Personal health budgets and integrated personal budgets

200,000 people benefitting from PHBs or IPBs

Specific Personalised Care commitments in LTP

• Provide people with a wide choice of options for quick elective care, including choice at point of referral and proactively for people waiting for six months (para 3.109)

• Use decision-support tools to augment the ability to deliver personalised care (para 3.106), and ensure the least effective interventions are not routinely performed, or only performed in more clearly defined circumstances, potentially avoiding needless harm to people and freeing up scarce professional time (para 6.17viii))

• Put in place over 1,000 trained social prescribing link workers by 2020/21 and over 900,000 people referred to social prescribing link workers by 2023/24 (para 1.40)

• Ramp up support for people to self-manage their own health (para 1.38) • Accelerate the roll out of Personal Health Budgets to give people greater choice and control over how care is planned and

delivered. Up to 200,000 people will benefit from a PHB by 2023/24 (para 1.41) • Support and help train staff to have personalised care conversations (para 1.37)

www.england.nhs.uk

What does good personalised care and support planning look like?

69 Its about a different conversation, starting

from a different place….. and

There are 2 key principles to personalised care and support planning….

……. seeing people as equal partners in the process

Personalised Care and Support Planning – Key features

Perspective – this is a way of ‘seeing people’ and attitude towards them that is fundamental to good Personalised Care and Support Planning. The changed relationship and different conversation will mean that the person: • is empowered and builds knowledge, skills and confidence • experiences hope and feels confident that the process and the plan will deliver what matters most to them • is central in developing their Personalised Care and Support Plan and will agree who is involved. • is seen as a whole person within the context of their whole life, valuing their skills, strengths, experience and important relationships • is valued as an active participant in conversations and decisions about their health and well being.

Personalised Care and Support Planning – Key features

Process – this is the overall process of personalised care and support planning A good Personalised Care and Support Planning process will mean that the person: • has the time and support to develop their plan in a safe and reflective space • is able to access information and advice that is clear and timely and meets individual information needs and preferences • feels prepared, knows what to expect and is ready to engage in planning supported by a single, named coordinator • is listened to and understood in a way that builds trusting and effective relationships with key people • is able to agree the health and well-being outcomes* they want to achieve, in dialogue with the relevant health, education and social care professionals • has the chance to formally and informally review their personalised care and support plan * and learning outcomes for children and young people with education, health and care plans.

Personalised Care and Support Planning – Key features

Plan – this is what a good plan looks like A Personalised Care and Support Plan: • is a way of capturing and recording conversations, decisions and agreed outcomes in a way that makes sense to the person. • should be proportionate, flexible and coordinated and adaptable to a person’s health condition, situation and care and support needs. • should include a description of the person, what matters to them and all the necessary elements that would make the plan achievable and effective.

www.england.nhs.uk

Understanding and sorting Important To & For

www.england.nhs.uk

“The quality of our lives depends on the presence or absence of things that are important to us” Michael Smull

for

Health and safety can dictate

Health and Safety dictate life

to

all choice no responsibility

All choice: No responsibility

. What is important to a person includes only what people are “saying”: -with their words -with their behaviour When words and behaviour are in conflict, listen to the behaviour.

Important to

. .

Important for

This includes only those things that we need to be mindful of regarding issues of health or safety and fulfilling potential. Think about…….. How best to support … to be healthy and safe What others need to know or do …

Hello my name is… Diane Burke, Head of Public Health (Long Term

Conditions) &

Louise Cresswell, Health Improvement Principal (Long Term Conditions)

Public Health, Leeds City Council

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Personalised Care and Support

Planning in Leeds

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Population of 751,485

There are 164,000 people in Leeds who live in areas that are ranked amongst the most deprived 10% nationally.

10 year life expectancy gap between the most deprived and most affluent areas

There are 141,771 people from BAME communities (19%) and over 85 languages spoken

99 GP practices; 1 CCG within

Leeds with different boundaries to LCC locality working

Leeds

People in the Population Health Management of Long Term Conditions cohort (n=292,000)

Grouped by age band and count of long term conditions in Leeds

Data Extracted from GP Clinical systems 2018.

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Attributable costs to LTC’s in Leeds (October 2018)

48% of all activity through the Health care system is for people living with LTC’s

47% of the overall budget

27% of all GP appointments

24% of all inpatient costs

Leeds Health and Wellbeing Board

In Leeds we believe wellbeing starts with people: The connections,

conversations and relationships between services and citizens and

between people in their families and communities have a huge impact on

us all.

Quality conversations make a difference, especially when used

positively by services to work ‘with’ people to find solutions rather than things being done ‘to’ people or ‘for’

them.

Our commitment to working with people is about bringing these beliefs to life, by

developing the skills and mind-set across Leeds’ health and care workforce to use

solutions that work with people wherever it is safe, appropriate and the right thing to

do.

Working ‘with’ means…

Better conversations: A whole city approach to working with people Focus on

‘what’s strong’ rather than

‘what’s wrong’

Actively listen to what

matters most to people

Start with people’s lived

experience

Put people at the centre of all decisions

Work as partners to

achieve individual

goals

Be ‘restorative’. Offer high

support and high challenge

Build on the assets in

ourselves, our families & our communities

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Enabling Systems and Processes

Engaged Informed Person

HCP committed to partnership

working ‘working with’

Commissioning and Involvement

Digital systems/ records Workforce systems – menu of training options

Neighbourhood asset based approaches – Better Together. West Yorkshire & Harrogate Health Care Partnership Personalised Care

Demonstrator Site - 2018/19

CCSP Better Conversations

PAMS Making Every Contact count Strength based Social Care

Digital Solutions Peer Support groups

Personal Health Budgets Structured/flexible

education programmes Leeds Directory

Social Prescribing Structured education Peer Support plan

Coproduction

Shared Decision making

The Leeds House of Care

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Hours with healthcare professional

= 4 hours in a year

Self-management

= 8756 hours in a year

Long term conditions are different

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• It is firstly about making routine consultations between clinicians and people with long term conditions truly collaborative, through care-planning - changing the relationship

• then about ensuring that the local services people need to support this are identified and available, through commissioning – changing support for self management

• It is not just about tools and structures, that it’s mostly about the relationship between the health care professional and person, an individual’s philosophy will determine how they communicate, work with and value patients contributions.

This creates an opportunity for people to feel more in control of their health.

Collaborative Care and Support Planning

Leeds Health and Wellbeing Board

This involves people, with a long term

condition(s), working with those delivering their care to make joint decisions and

agree how their long term conditions will be

managed.

One of the key elements is sharing the results of annual

checks, so that people with a long term

condition(s) have a chance to think about

their results before their Care and support Planning appointment.

Information Gathering

Information Sharing

Consult and joint decision

making. Agreed shared goals and action plan

1st Visit Between Visits 2nd Visit

During the annual review process

Disease surveillance

Tests and checks

performed where

needed

Preparation Results/ agenda setting

prompts sent to patient

> 1 week before

conversation

Conversation

A meeting of equals and experts

Prepared practitioner and patient:

review how things are going consider what's important

• share ideas • discuss options

• develop a care plan • Agree on goals

‘A Collaborative Care and Support plan is at the heart of a partnership approach to care and a central part of effective care management. The process of agreeing a care plan offers people active involvement in deciding, agreeing and owning how their condition is to be managed’

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• Collect useful and important information

• Be clear about the two appointment process and receiving the results

• Time between appointments allows for time to consider what people wants to get out of the consultation

• Take time to think and talk with other people what matters most

Prepared and Informed people

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Care planning – it’s a verb

‘A care plan is at the heart of a partnership approach to care and a central part of effective care management. The process of agreeing a care plan offers people active involvement in deciding, agreeing and owning how their condition is to be managed’

Partnership working

Individual patient choices via the care planning process = micro-level commissioning

Individual choices & population care MENU OF OPTIONS: Examples

Support for Self management

• Patient Education

• Weight management

• Smoking cessation

• Better Conversations

• Exercise programmes

• Health Coaching sessions

• Community support: Buddying / walking groups…

• Tele care

• Social prescribing

• Leeds Directory

• Personal Health Budget

• Forward Leeds

• Peer Support

Coordinating clinical / social input

Population level decision making and service delivery based on actual needs of individuals

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• Implemented in all 99 GP Practices • 65,515 people have had a annual review

using the CCSP approach (April 18 - Dec 18)

• Over 600 HCP have attended the training

Current picture

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Impact Data for Leeds CCG, National Diabetes Audit (T2) (95% of practices)

Attainment of measure 2016/17 2017/18

Type 2 Diabetic patients receiving

all 8 care processes* 49.30% 66.40%

*Data from the National Diabetes Audit. The England average for all 8 care processes in 2017/18 is 58.8% (8 care processes are HbA1c, Blood Pressure, Cholesterol, Serum Creatinine, Urine Albumin, Foot Surveillance, BMI & Smoking

Our Journey

6 GP practices early implementors - Evaluated by LBU

2014

2013

2015

2017

Monthly workforce training sessions

YOC – Nesta quality assured train the trainers

Secured CCG funding for city wide roll out

Developed City wide template

PC Facilitator post to embed in practice

Recruited GP champions

In House – taster sessions 2016

Developed Practice manager & Admin training

436 staff trained

2018

CCG Merge

Template review

Half day training developement

Included within QIS

Embeded trianing within BC

Sustainable model of training

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• Senior leadership buy in • Quality Improvement Scheme • City wide approach – train the trainers • Primary care facilitator • GP buy in • Clinical Template for consistency/data

quality • Funding • Culture change – Workforce

Enablers

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• Different approaches across the city (3 CCGs)

• Reliant on good will – Training • Disengaged GP practices • Clinical template • Evidence – outcomes

Challenges

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Next Steps - system • Helm – Person Held Record • Quality improvement to understand the

requirements of sharing the care plan and clinical information across Health & Social care organisations

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• Commissioned insight work – Results, goals, conversation

• Patient Engagement group • Coproduction – personalised care. • ‘What matters to me’ – Person Centred Care Plan

Next Steps - working with people with lived experience

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Personalised Care & Support Planning What is happening in Places and how you can find out more

Bradford Calderdale Harrogate Kirklees Leeds Wakefield PCSPs for PHB are in place. People with long-term conditions have Personalised Care Plans

LOTAs have been introduced for children with life limiting conditions at CHFT

Educational & Health Care Plans (EHPs) for children in place. Patients with MH or LD all have care and Treatment Review plans in place.

GOMPs in place within community services. Learning Disability Personalised Care process Defining a consistent approach to personalised care planning across Kirklees.

Train the trainer programme in place. CCSP has continued within the city. Embedding the approach of ‘better conversations’, all GP practices are now engaged in this process.

Education and Health Care Plans and Care plans in care homes to be holistically driven with an emphasis on Advance Care Planning for care homes for 65`s in Wakefield.

Bridget Jones Bridget.Jones@bradford.nhs.uk

Sarah Antemes Sarah.Antemes@calderdaleccg.nhs.uk

Paula Middlebook paula.middlebrook@nhs.net

Rachel Millson Rachel.Millson@northkirkleesccg.nhs.uk

Diane Burke Diane.Burke@leeds.gcsx.gov.uk

Pam Sheppard pam.sheppard@wakefieldccg.nhs.uk

Discussion and Questions

Question:

• What can we do together across WY&H?

• What can we do individually? • How do we embed personalised care in

our work?

Hello my name is… John Walsh, OD Lead,

Leeds Community Healthcare NHS Trust &

Alyson McGregor, Director Altogether Better

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Collaborative Practice is a new way of organising • Deals with the things that medicine cannot fix

• Supports staff to work collaboratively

• Practices understand and use their data to make better decisions

• Invite local people to gift their time to coproduce new solutions

• The new extended team/family develop a range of new offers • Clinicans & staff connect patients to new offers

• Meets demand and reduces pressure

• It’s BETTER FOR EVERYONE

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“ coming along has turned the lights back on for me”

The relationship determines the outcome

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1 + 1 = 2

Alyson McGregor: 07780593409 John Walsh:07960828285

e: alyson.mcgregor@swyt.nhs.uk john.walsh@nhs.net

@al2getherbetter @johnwalsh88

altogetherbetter.org.uk

Join our workshop or chat to us

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Workshops

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Shared Decision Making Sarah Antemes

Place Lead for Calderdale

Format of the workshop

Topic Presenter Time

Introduction Sarah Antemes 13:55

Shared Decision Making (SDM) – Context and Impact

Surfraz Ahmed Pauline Grant

14:00

Experience of adopting SDM within LCH MSK service

Steve Laville 14:10

Shared Decision Making in the Calderdale Staying Well programme

Vicky McGhee Rachel Swaby

14:25

Shared Decision Making in Calderdale Healthy Minds

Jonny Richardson Glenn 14:40

Conclusion Sarah Antemes 14:55

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Introduction

Sarah Antemes – Place Lead for Calderdale • Purpose • Presentations • Opportunity for questions and answers

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Shared Decision Making: A different conversation…

Pauline Grant Deputy Policy Lead Shared Decision Making and Health Literacy Saf Ahmed Policy Officer Shared Decision Making and Health Literacy 25th February 2019

@ThePaulineGrant @SurfrazAhmed

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Shared Decision Making

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Clinicians

Patients

Together they make a decision

• Best evidence

• Clinical expertise

• Patient expertise

• Individual patient preference

Conversation between

equals

Why is SDM important?

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It can create a new RELATIONSHIP between individuals and professionals based on partnership (Mulley et al, 2012).

People want to be more INVOLVED than they currently are in making decisions about their own health and health care (Care Quality Commission inpatient survey, 2016; NHS England, GP survey. 2017).

Both individuals and clinicians tend to consistently OVERESTIMATE the benefits of treatments and UNDERESTIMATE the harms (Hoffman, 2017).

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Why is SDM important?

• .

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It has the potential to ENHANCE allocative efficiency and REDUCE unwarranted clinical variation (Mulley et al, 2012).

It is a LEGAL requirement and health professionals now must take “reasonable care to ensure that the patient is aware of any material risks involved in any recommended treatment and of any reasonable alternative or variant treatments”.

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Top goals and concerns in breast cancer decisions

Doctors Patients

Sepucha et al. (2008). Pt Education and Counseling. 73:504-10

What do you think might be the top goals and concerns in breast cancer conditions?

When is it appropriate?

Reduction in referrals and reduced spend

• In Bedfordshire 35% of patients having an SDM discussion choose alternative options to surgery resulting in a 24% reduction in Secondary Care referrals.

• Pennine MSK Partnership reported that

Arthroscopies grew at 8% in Oldham compared to 12% nationally and Musculoskeletal spend per head decreased by £10 in Oldham compared to an increase of £10 nationally.

Improving efficient use of services

And what about health literacy?

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43% - 61% of English working age population do not understand health information they are given (Institute of Health Equity/Public health England 2015)

There is a strong social gradient in the population, with lower levels of health literacy much more common among the socially and economically disadvantaged ie it impacts on health inequalities.

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What good shared decision making looks like for the system

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Another way to share decisions(!)

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Experience of adopting SDM within LCH MSK service

Steve Laville Senior Commissioning Manager

NHS Leeds CCG

Why adopt SDM?

• Proposal was originally made by NHS LSE CCG clinical leads

• Objective - better informed decisions o Realistic expectations o Confidence that the right choice has been made o Reduction in overtreatment

• Improved patient experience

• Improved patient outcome

Where to adopt SDM • Situations where patients are faced with

preference sensitive choices

• Additional element of existing pathway step – Not additional pathway step

• Where we could realistically assess its impact

• NHS Leeds Community Healthcare MSK service

How we introduced SDM • Initial engagement between CCG Commissioners, and LCH MSK service clinical leads and managers

• Extensive external SDM training delivered – commissioned by the 3 Leeds CCGs

• MSK Service wide strategy for dissemination :- o Policy adopted that all patient facing staff receive appropriate training o All patients are provided with information outlining the support they will

receive, and asked to prepare any questions they may like to ask in advance

• GP comms exercise

• Programme Launched April 1st 2015

Specific project objectives

1. To ensure that in all situations where a patient faced preference sensitive treatment options, the patient would be supported in making this decision through a structured SDM process

2. To measure how well supported patients felt in

making their treatment decision 3. To measure the outcomes of the SDM discussions – in

particular, how many patients opt for orthopaedic opinion with a view to considering surgery

• Between April 15 – February 16, 2,531 SDM discussions were read coded

• Service Clinical Lead also confirmed that the SDM training had been highly valued by all the practitioners who received the training

• Did mark a cultural shift – informing all consultations

• Shift away from prescriptive or directive provision of care, to

a more inclusive approach

What Happened – Objective 1 Patients being supported in decision making through a structured SDM Process

What Happened – Objective 2 How patients felt about SDM • Independent monthly telephone follow-up carried out by Leeds

Involving People • Low take up, but the responses that were given were

overwhelmingly positive • 114 responses – on a score of 0 (terrible) to 9 (outstanding)

o 101 patients scored 8 or 9 to the question “How much effort was made to understand your health issues?”

o 101 patients scored 8 or 9 to the question “How much effort was made to listen to the things that matter most about your health issues?”

o 100 patients scored 8 or 9 to the question “How much effort was made to include what matters most to you in choosing what to do next?)

What Happened – Objective 2 How patients felt about SDM

Summary of Patient Views Yes No N/A

Did you feel sure about the best choice for you? 104 9 1

Did you know the benefits and risks of each option? 104 9 1

Were you clear about which benefits and risks matter most to you? 104 9 1

Did you have enough support and advice to make a choice? 105 8 1

MSK Discharges to orthopaedics and spinal surgical services

5800

6000

6200

6400

6600

6800

16/17 17/18 18/19

4600470048004900500051005200530054005500

14/15 15/16

What happened – Objective 3 Comparative outcomes following SDM discussions

Lessons Learned/Points to Consider • Lots of people think that they routinely deliver SDM, when

actually, they don’t. (Unless you have been specifically trained to do it, you probably don’t do it)

• High quality training was really valuable

• It cannot just be dropped into the pathway – it has to be a culturally integrated element of how services are provided, at every stage of the pathway

• It has to be swallowed whole – requiring strong leadership and credible clinical champions

• Manage the message! It is all about paying attention to improving people’s lives on their terms.

• Really, there is no excuse for not doing it.

Shared Decision Making is a collaborative process aimed achieving an optimal outcome

Clinicians

• Clinical knowledge • Treatment options • Benefit and risk

Patient

• Person-specific knowledge • What is important to them • Appetite for risk

Shared decision making

discussion

Plan to achieve optimal

outcome

Overtreatment Be very careful in how you use this term! • It is not about cutting costs. • It is about making sure that patients receive

treatments that best match their objectives and expectations.

• Preventing overtreatment means preventing patients from receiving treatment where the harms have outweighed the benefits.

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Shared Decision Making in the Calderdale Staying Well Programme

Vicky McGhee & Rachel Swaby

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A Staying Well key worker meets

the person and discusses ways to

improve their quality of life and

wellbeing.

The Route to Wellbeing: the Staying Well model Staying Well is social prescribing service for Calderdale.

Adults are referred to Staying Well

through a variety of sources

Promotes independen

ce

Expands horizons

Person Centred

Flexible

Underlying Principles

Social Care

NHS

GPs

Friends and Family

Community Groups

Self referral

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The Route to Wellbeing: the Staying Well model Staying Well is social prescribing service for Calderdale.

Options available to an individual include

New social activities funded

Access to other formal

services

Continuing support

Linking to a community

activity

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“When you make someone a cup of tea,

especially a proper cuppa in a teapot,

you’re saying, ‘here is some of my time,

we can chat if you want to but I’m

going to make you a brew and drink it

with you’”.

Helen, Staying Well Worker

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Shared decision making at all levels

Calderdale Council

Strategic Delivery Group

Local Steering Groups

VCS Anchor Organisations

Staying Well Workers

Person

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Shared Decision making in Healthy Minds

Jonny Richardson Glenn

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Welfare / benefits

Debt Volunteering

Roshani: BAME mental health

10 -19 years

Recovery Courses & Workshops

Anxiety Anger

Confidence Creativity Mood

Loneliness Assertiveness

Out-of-hours crisis support

Employment support

Peer Support Groups

Allotment Walking

Janet

Long history of MH problems

Difficulty accessing NHS MH services

Professional role: stigma

Despair

Exhausted ‘usual’ avenues

Isolated

Janet

Long history of MH problems

Difficulty accessing NHS MH services

Professional role: stigma

Despair

Exhausted ‘usual’ avenues

Isolated “Through Healthy Minds I have not just learnt skills and techniques to help me manage my conditions, but to do so without fear of judgement, amongst an understanding community. Nowhere else have I experienced this extra step of real-world practice. They just get what I need.”

Out-of-hours crisis support

Employment support

Peer Support Groups

Allotment Walking

Recovery Courses & Workshops

Anxiety

Anger

Confidence

Creativity

Mood Loneliness

Assertiveness

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Conclusion Sarah Antemes

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Coffee break

Hello my name is… Ian Holmes – Director, West Yorkshire and

Harrogate Health and Care Partnership

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Q&A panel

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Next steps

Close and Networking

Further information

• Visit www.wyhpartnership.co.uk • Weekly blog www.wyhpartnership.co.uk/blog • ‘Our Next Steps’ www.wyhpartnership.co.uk/next-steps • Follow: @wyhpartnership