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Person-centred careHealth Foundation resources
December 2015
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CONTENTS
1. Health Foundation programmes (person-centred care) 3
Closing the Gap through Changing Relationships 3
Shine 7
Co-Creating Health (ran from 2007-2012) 22
Self Management Support (2013-2015) 23
MAGIC (Making good decisions in collaboration) (2010-2013) 24
2. Publications 24
3. Person-centred care resource centre 25
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1.Health Foundation programmes (person-centred care)
Closing the Gap through Changing Relationships
From 2011 seven teams have been working on projects that aim to change the relationship between people and health services. To organise healthcare services around the needs of the people using them, the Health Foundation believes there needs to be a shift in philosophy, culture and behaviour in three key relationships:
Between communities and the wider healthcare system. Services do not always take account of local community factors such as cultural expectations, knowledge, language and access, meaning there can be a gap between the services provided and what communities actually need.
Between the person using services and the wider healthcare system. The responsibility to ‘join up’ services is frequently with the user rather than the service provider.
Between the individual and health providers. Effective interactions require both parties to have a shared understanding of purpose and process.
EvaluationThe evaluation from this programme can be found here: http://www.health.org.uk/publication/closing-gap-through-changing-relationships-evaluation
The seven projects which ran until end of May 2013 are as below:
Mid-Staffordshire NHS Foundation Trust & the Patients AssociationSpeaking up: Resolving NHS complaints and preventing problems from recurring
Project summaryThis project seeks to transform the current complaints system, creating greater transparency, scrutiny and independence and building a new relationship between the local community and the Trust through a new complaints ‘patient champion’ role. It will ensure that learning from complaints is harnessed and used to improve future care by recording complainants’ ‘patient voices’ – reflective digital stories of patient care for use as teaching resources.
Website Link: http://www.health.org.uk/areas-of-work/programmes/closing-the-gap-through-changing-relationships/related-projects/resolving-complaints-and-preventing-problems-from-recurring/
University College London Hospital CharitiesPromoting compassionate healthcare for homeless people
Project summaryMost rough sleepers and homeless people have physical and mental health problems, combined with drug or alcohol misuse in a life lacking routine and social support. These
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factors often cause friction between homeless service users and hospital staff, resulting in a lost opportunity to engage with the individual to help plan and coordinate future care. This project seeks to bring greater compassion and skill to homeless healthcare, by changing the relationship between healthcare professionals and the street-homeless community in order to improve experience and outcomes.
Primary contact detailsAlex BaxEmail: [email protected]
Website Link: http://www.health.org.uk/areas-of-work/programmes/closing-the-gap-through-changing-relationships/related-projects/promoting-compassionate-integrated-patient-centred-healthcare-for-homeless-people/
Nottinghamshire Healthcare NHS TrustTransforming the culture of mental health services through peer support
Project summaryAround one in four people are thought to suffer from mental health problems at some point in their life, but mental ill health continues to carry a stigma. This has a huge impact on the lives of those experiencing mental health problems and the attitudes and behaviour of those around them, including healthcare professionals.
This project seeks to transform the culture of mental health services by employing peer support workers to inspire hope, promote recovery and challenge discrimination. It is built on the belief that people who experience mental health problems can embody recovery and challenge people’s expectations.
Primary contact detailsJulie Repper, Email: [email protected]
Website Link: http://www.health.org.uk/areas-of-work/programmes/closing-the-gap-through-changing-relationships/related-projects/transforming-the-culture-of-mental-health-services-through-peer-support/
University College LondonM(ums)-Power: putting women at the centre of antenatal care
Project summaryPregnancy is a normal physiological process that produces a range of changes and anxieties that most women manage within complex, busy lives. But services often meet the priorities of healthcare professionals rather than the needs and preferences of the women they serve, resulting in dissatisfaction, inefficiency and, for some, a reluctance to engage.
The funding provided by The Health Foundation’s Closing the Gap programme is being used to transform both the effectiveness and the person-centeredness of antenatal care.
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M(ums)-Power seeks to do this through improving the culture of antenatal services, with the ultimate aim of transforming the dynamic between those who use antenatal services and those who provide them.
Primary contact detailsProfessor Donald Peebles,Email: [email protected]
Website Link: http://www.health.org.uk/programmes/closing-gap-through-changing-relationships/projects/mums-power-putting-women-centre
Child and Adolescent Mental Health Services (CAMHS) at University College London & the Anna Freud CentreShared decision making in child and adolescent mental healthcare
Project SummaryWhen children, young people and their families reach mental health services, they are often bewildered and vulnerable. They may not feel confident about how best to ensure their feelings and wishes are genuinely taken into account.
This project seeks to enable children, young people and their families to make informed choices and become active partners in their treatment. It will support them to contribute to decision making and ongoing review of progress. It will help them, and those working with them, find ways to agree goals and review outcomes in ways that are supportive, collaborative and respect the individual's choice.
Primary contact detailsDr Miranda WolpertEmail: [email protected]
Website Link: http://www.health.org.uk/areas-of-work/programmes/closing-the-gap-through-changing-relationships/related-projects/promoting-choice-and-collaboration-in-child-and-adolescent-mental-healthcare/
NHS Alliance myRecord project: turning it on, sharing the learning Project SummaryToday 60% of GP practices have the technology in place to allow patients 24-hour online access to their own patient records, but so far only 50 UK practices have seized the opportunity.
For many, the notion of allowing patients access to their own medical records raises fears of increased workloads, misuse of data and harm to patients or the practice. But evidence and experience shows that these concerns are unfounded, and that the approach improves quality of care, shared decision making, safety, effectiveness and patient experience.
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This project will work with practices to create a cultural and attitudinal shift to make record access standard practice.
Primary contact detailsDr Brian Fisher,Email: [email protected]
Website Link: http://www.health.org.uk/areas-of-work/programmes/closing-the-gap-through-changing-relationships/related-projects/patient-record-access/
myRecord Website: http://myrecord.org.uk/
Sheffield Teaching Hospitals NHS Foundation TrustEnabling self-management and shared haemodialysis care in hospital based dialysis
Project SummaryEvery year, 20,000 people in the UK with kidney disease receive dialysis, which usually takes 3-4 hours at a time, 3 times a week.
Although a small proportion of people in the UK manage their own dialysis at home, for most people it requires many hours every week in hospital. Dialysis is therefore a life-saving but demanding routine. There is evidence that it often leaves people feeling helpless and dependent on hospital staff, as well as having a huge impact on the lives of patients and their families.
This project will rebuild independence, control and flexibility for patients by enabling them to manage their own treatment within hospital. It also aims to transform the relationship between dialysis unit staff and patients, with staff freed up from technical tasks to become health coaches and educators, using the many hours spent in the hospital as an opportunity for building self-management skills and facilitating education and peer support.
Primary contact detailsDr Martin Wilkie, Email: [email protected]
Website: http://www.health.org.uk/areas-of-work/programmes/closing-the-gap-through-changing-relationships/related-projects/from-dependency-to-control-enabling-self-dialysis-in-hospital/
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Shine
Our annual Shine programme aims to stimulate thinking, activity and the development of innovative approaches that will improve healthcare quality. It gives teams the space and encouragement to try out, develop and evaluate new ideas.
Shine 2010
NHS Gloucestershire - 3 Counties Cancer Network
Project SummaryThe focus of this project was to inform and support patients to allow them to have a greater involvement and responsibility for their own chemotherapy treatment specifically to improve the management of toxicity assessment in chemotherapy.
The project team wanted to transform chemotherapy services through: increasing the efficiency of the chemotherapy toxicity assessment process increasing the effectiveness of the chemotherapy toxicity assessment process
through developing a multi-disciplinary, systems-based approach that is transferable to an electronic chemotherapy record
supporting nurse and pharmacist-led chemotherapy toxicity assessment.
Primary contact detailsPeter DaviesEmail: [email protected]
Website: http://www.health.org.uk/areas-of-work/programmes/shine-ten/related-projects/three-counties-cancer-network/
Shine 2011
NHS Redbridge Empowering patients in high quality chronic obstructive pulmonary disease (COPD) care
Project Summary
The Shine 2011 team at NHS Redbridge is introducing an initiative that involves providing individualised information to patients and their GPs that will empower them both to raise the standard of COPD care.
They have developed an IT system that can extract data from primary care databases, and track quality and cost of care for individual patients. Patients are sent their report; a letter advising them to request an appointment with their GP to discuss what further interventions could be made; and information about community-based services that may allow exacerbations to be managed at their home, rather than in hospital.
The reports will enable GPs to identify gaps in care at the individual patient level and they can then work with the patients to improve care, either during routine clinic
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appointments, or appointments arranged by patients to specifically discuss their quality report.
Primary ContactAngela BurrowEmail: [email protected]
Website: http://www.health.org.uk/areas-of-work/programmes/shine-eleven/related-projects/nhs-redbridge/
Newham University Hospital NHS TrustWeb based outpatient consultations in diabetes
Project Summary
The Newham Shine 2011 project involved replacing routine follow-up outpatient appointments that don’t require physical examination with web-based consultations. These consultations were offered to all patients attending the transitional and young adult service, and for all patients under a consultant in the general diabetes clinic.
The project had a significant impact on patients, particularly those who have difficulty accessing care due to their busy lifestyles or multiple commitments; and those with limited mobility or who are housebound. For staff it encouraged more focused consultations and better use of face-to-face time for clinical activities.
Continued fundingWe are continuing to fund this project for another two years where the team will looking at the role of web-based consultations in increasing self-management through improved interaction between health professionals and patients, and providing a more proactive and flexible model of outpatient care.
Primary Contact
Shanti VijayaraghavanEmail: [email protected]
Website: http://www.health.org.uk/areas-of-work/programmes/shine-eleven/related-projects/newham-university-hospital/
Blog – a new DAWN: http://blogs.diabetes.org.uk/?p=617#more-617
NHS Bolton: Alcohol relapse prevention programme
Project Summary
The Shine 2011 team at NHS Bolton is implementing a relapse prevention programme that uses mobile phone technology. The programme consists of multiple phases that can overcome communication barriers between the client and the service, and provide
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contact during the periods between formal appointments, when the client is most in danger of relapsing.
The first phase is a text-based appointment reminder system, with an opportunity for the client to confirm whether they will be attending their aftercare appointments or not. The second phase is a ‘mood monitoring’ survey where clients are contacted a few times a week via text message with simple questions about their feelings and emotional state. This will trigger a response, the level of which depends on the answers given. The third phase allows clients to contact the service in the event of a relapse or if they are experiencing cravings. This provides clients with a secure way of obtaining support and advice when they most need it.
Consistent texts will help clients focus on their goals and stay on track. If a client is in an emergency situation, motivational advice or personal contact will help drive abstinent behaviours and help prevent relapse.
Key contactDebra MaloneEmail: [email protected]
Website: http://www.health.org.uk/areas-of-work/programmes/shine-eleven/related-projects/nhs-bolton/
Shine 2012
2Gether NHS Foundation TrustCoaching for recovery: active mental health long term condition management
Project summary
1,606 adults in Gloucestershire and Herefordshire currently access specialist mental health services for treatment and management of psychosis. Long term mental health conditions can often be successfully treated with medication resulting in stable psychosis. However, the vast majority of people with this diagnosis experience poorer quality of life outcomes than the general population.
Our vision is to offer people with long term psychosis the opportunity to take charge of their care and tell us how we can offer more personalised and recovery focused care. We want to build on work to train our staff to use an approach that supports the individual’s recovery and reduces reliance on specialist care.
Firstly, we plan to pilot ‘pop up recovery colleges’ to build knowledge, skills and confidence. Secondly, we will conduct a series of PDSA cycles to learn how we can best introduce recovery care plans that build on a person’s strengths, set their own goals and offer coaching and support.
Primary contact detailsTim Coupland, Gloucestershire Localities Development & Performance Lead, Ambrose House, Gloucester, GL4 3GG.T: 01452 894784 or 07919 626489
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Birmingham Children’s Hospital NHS Foundation TrustSupporting parents/carers to be active partners in their child’s care: quantifying parental concern to strengthen their voice
Project summary
Parents have a unique insight about their child’s health and Birmingham Children’s Hospital (BCH) actively encourages families to be involved in the care of their child. There is currently no assessment tool available within the NHS to capture those parental observations about when a child might not be ‘themselves’.
Currently the NHS relies on verbal communication between clinical teams and families around particular parental observations, which can sometimes be open to interpretation around the level of concern and the appropriate resulting action. BCH takesparental concerns just as seriously as other healthcare observations. This project aims to bridge this gap by working in partnership with families to develop a new parental observation framework.
Primary contact detailsVictoria Demery, Safer Clinical Handover Project Manager, Birmingham Children’s Hospital NHS FT, Steelhouse Lane,Birmingham, B4 6NH. T: 0121 333 8611 E: [email protected]
Website link: http://www.health.org.uk/areas-of-work/programmes/shine-twelve/related-projects/birmingham-children-s-hospital-nhs-foundation-trust/
Cambridge University Hospitals NHS Foundation Trust - COPD Supporting patients to inform clinical commissioning to achieve best outcomes; the value of planning using patient-centred information
Project summary
COPD (Chronic Obstructive Pulmonary Disease) is a long term condition (LTC) causing disabling breathlessness, leading to inactivity and worsening health status. If well managed with appropriate support, quality of life improves and hospital admissions can be reduced but we need to understand how best to implement support and what form is most helpful to patients.
Issues identified relating to patients getting the right support are:
1. Access to services that they recognise as appropriate and relevant
2. Existing COPD services are developed around the medical model and do not address the practical, social and emotional aspects of patients’ lives
3. The commissioning process needs to be informed by patients’ experiences, needs and aspirations.
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There is no systematic means of empowering patients to inform commissioning so that services address patients’ needs and aspirations. We propose implementing a systematic process called Working Together For Change (WTfC) to realise patient co-production in the commissioning of COPD services in Cambridgeshire.
Primary Contact Details: Tracy Watts, Lead for Patient Development, Flat 62 Elsworth House, Addenbrooke’s Hospital, Cambridge, CB1 0QQ T: 07951192282 E: [email protected]
Website link: http://www.health.org.uk/areas-of-work/programmes/shine-twelve/related-projects/cambridge-university-hospitals-nhs-trust/
Cambridge University Hospitals NHS Trust, Urogynaecology Enabling patients using vaginal pessaries for Pelvic Organ Prolapse to reduce their hospital attendances through self-management
Project summaryVaginal pessaries provide an effective alternative to major surgery for women with Pelvic Organ Prolapse (POP). In the UK, the management of patients who have pessaries requires an attendance every six months to have the pessary changed by a healthcare professional. The two primary drawbacks to this pathway are that:
1. Precious outpatient consultant capacity is used
2. Patients with POP who use a vaginal pessary are committed to life long six monthly follow up to change their pessary. The time commitment combined with the nature of the procedure, which for many is stressful and causes discomfort, is felt to be the leading cause of women stopping pessary use and moving to surgery.
Under the self management pathway, patients would attend an outpatient appointment to discuss the option of a pessary and would receive guidance on insertion and removal by a clinical nurse specialist. They would be able to contact the nurse specialist if they had any problems, but would only need to come back into clinic every 24 months.
Primary Contact Details: Dr Rohna Kearney, Consultant Urogynaecologist, Box 242, Dept of Gynaecology, Addenbrooke’s Hospital, Hille Rd, Cambridge, CB2 0QQ. T: 01223 586740 E: [email protected]
Website link: http://www.health.org.uk/areas-of-work/programmes/shine-twelve/related-projects/cambridge-university-hospitals-nhs-foundation-trust-self-management/
Children’s Hospice South West Promoting Patient and Carers’ Priorities in Care – MyQuOL-T: a simple, individualised IT approach to improving care in long-term and life limiting conditions
Project summaryChildren and young people receiving palliative care for long-term or life-limiting illness have complex symptoms with consequences which can impact negatively on the whole
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family's health and wellbeing. Professionals struggle to know which issues matter most to the child and family and so how best to help improve their quality of life.
My QuOL-T (Measure Yourself Quality of Life Tool) is an innovative web-based application that helps patients to identify, describe, prioritise and monitor health related problems or symptoms that are important to them. We plan to introduce the use of My QuOL-T to children and families attending the children's hospice and monitor the acceptability, accessibility, use and effectiveness of the tool.
Primary Contact Details: Pennee Paige, PA, Charlton Farm, Children’s Hospice South West, Charlton Drive, Wraxall, near Bristol, North Somerset BS48 1PE T: 01275 866615 E: [email protected] or [email protected]
Website link: http://www.health.org.uk/areas-of-work/programmes/shine-twelve/related-projects/children-s-hospice-south-west/
Hampshire Hospitals NHS Foundation Trust ‘Coaching for recovery’ – Liberating the voices of all to maximise patient partnership in acute care settings
Project summary
The acute care environment disempowers and debilitates individuals mentally and physically which, for elderly or vulnerable service users, may mean that they require prolonged rehabilitation and care or become unable to return home. The impact of this is very significant for our patients, their families and all components of acute, community and social care capacity.
Despite improving our rehabilitative interventions we have maintained, unintentionally, an environment of ‘tell’ rather than ‘coach’. We need to change the game.
Our theory is that by changing the quality of the conversations had and the language used by all we will liberate the patient and ourselves to become partners in the care relationship as opposed to being care givers and the passive recipients of care. Much time is spent training staff in clinical skills, and little time in how to deliver the message, promote partnership and encourage patients to participate fully in their recovery, discharge and long term outcomes. The proposal is that we use the concept of Health Coaching and move the concept to ‘Recovery Coaching’.
Primary Contact Details Beverley Harden, Associate Director Workforce and Education, CNO Office, Top Floor, Ashley Wing, Royal Hampshire County Hospital, Romsey Road, Winchester, Hampshire, SO22 5DG T: 01962 824296 E: [email protected]
Website link: http://www.health.org.uk/areas-of-work/programmes/shine-twelve/related-projects/hampshire-hospitals-nhs-trust/
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HealthQuest Solutions Ltd. my COPDsolution - Delivering self management, reducing wasteful prescribing and improving compliance in patients with Chronic Obstructive Pulmonary Disease (COPD) through a web based system and holdall
Project summary
The latest guidance for COPD from NICE has patient self-management at its heart but there are currently no bespoke patient solutions provided for the UK market that enable fulfillment of this ambition. Self-management plans are often delivered with inadequate local solutions. Our proposed solution is an IT based system that can deliver a UK wide solution to patient self-management.
Primary Contact Details: Simon Bourne, Director HealthQuest Solutions Ltd, 2 Venture Road, Chilworth, Southampton, Hants. SO16 7NP T: 07976 395850 E: [email protected]
Website link: http://www.health.org.uk/areas-of-work/programmes/shine-twelve/related-projects/healthquest-solutions-limited/
Portsmouth Hospitals NHS Trust “My Birthplace” - The development of a computerised decision making tool to support women, their partners and midwives to make a decision about place of birth
Project summaryPortsmouth offers a full range of options for place of birth; home, three standalone midwifery led units, an integrated midwifery led unit and a consultant led labour ward. However, a third of women are still undecided about place of birth when they go into labour. They are largely unaware of the recent evidence from a large prospective cohort study-Birthplace (Holliwell et al 2011), showing that birth is safe in midwifery led settings for low risk women and intervention is reduced. The out of hospital birth rate is only 10.9%.
Women have written information about birth place choices but there is often subjective information from midwives. We aim to develop a simple computer based decision making tool to support shared decision making, with associated training for midwives and parents to be.
Primary Contact Details: Gill Walton, Director of Midwifery, Maternity, Queen Alexandra Hospitals, Portsmouth PO6 3LY T: 023 9228 6000 ext 4532 E: [email protected]
Website link: http://www.health.org.uk/areas-of-work/programmes/shine-twelve/related-projects/portsmouth-hospitals-nhs-trust/
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Sheffield Teaching Hospitals NHS Foundation Trust Improving self efficacy in Spinal Cord Injury patients through ‘Design Thinking’ rehabilitation workshops
Project summary
Spinal Cord Injury (SCI) is a life-changing event. Advances in surgical and medical management of these patients have significantly reduced the length of stay of SCI patients. However, it has left patients with less time to psychologically adjust to the devastating loss of function. In all cases of SCI, patients have to drastically change the way they think about life in general and about the adjustments in their environment in particular.
Alongside the traditional therapies, patients are ‘offered’ solutions to aid their rehabilitation, and there is limited contribution that the patient makes towards modifying their own environment. The proposed solution is a series of design thinking workshops with small groups of SCI patients over a six month period that will promote design thinking and self efficacy.
Primary Contact Details Daniel Wolstenholme, Clinical Research Fellow, Sheffield Teaching Hospital, 14, Claremont Crescent, S10-2TA T: 07899 083052 E: [email protected]
Website link: http://www.health.org.uk/areas-of-work/programmes/shine-twelve/related-projects/sheffield-teaching-hospitals-nhs-foundation-trust/
Sloan Medical Centre Please stop informing me: Enabling people to use internet information to self-manage musculoskeletal pain
Project summary
We know that one third of the population in Sheffield lives with persistent pain, with 4-10% having severe pain requiring regular medical input. There is a significant gap in service delivery which we do not believe is adequately provided for by primary care with current tools and resources.
At the most basic level, interventions are needed that can promote the development of health literacy. We need to improve individual capacity through the provision of good information on how to self-manage chronic pain, with appropriate support to enable the development of health literacy.
Currently we have fairly ‘adhoc’ administration of health advice and information for people living with chronic pain. A small proportion of people will attend a pain clinic, and a small proportion of people will receive some input from physiotherapists, their GP, or a health trainer.
We will look at co-produced, web-based information and tools, accessed individually or with support, to establish pragmatic methods of improving health literacy. We hope the lessons we learn will inform commissioning frameworks for effective pain management in the future.
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Primary Contact Details: Dr Ollie Hart, GP partner, Sloan Medical Centre, 2 Little London rd, Sheffield, S8 0YH. T: 07968775030 E: [email protected]
Website link: http://www.health.org.uk/areas-of-work/programmes/shine-twelve/related-projects/sloan-medical-centre-sheffield/
University College London Hospitals NHS Foundation Trust Supporting Patients to be active participants in improving anticoagulant medication safety
Project summary
Anticoagulants are one of the classes of medicines most frequently identified as causing preventable harm, admission to hospital (NPSA, 2006; Piazza et al., 2011) and fatal medication incidents (MDU, 1996).
We will carry out a 15 month study which aims to develop, test and spread two innovations: i. Patient-led discharge summary ‘time outs’ (involving patients in reviewing the content of their discharge summary prior to discharge will improve communication between the hospital and GP). ii. Developing patient-centred run charts which present INR test result, drug dose and target INR level in a pictorial format (this educational tool will engage patients in understanding their anticoagulant management plan).
Primary Contact Details: Sandra Hallett, Director of Quality and Safety, Level 2 Central, 250 Euston Road. London. NW1 9PG T: 0203 456 7890 E: [email protected]
Website link: http://www.health.org.uk/areas-of-work/programmes/shine-twelve/related-projects/university-college-london-hospitals-nhs-foundation-trust/
Shine 2014
Cardiff and Vale University Health Board: Fast-track group intervention for low back pain patients
Lower back pain has a significant impact on individuals and society. Research has highlighted the importance of a patient-centred and bio-psychosocial approach to the management of the condition.
Psychosocial factors are more predictive of disability, yet both patients and therapistsmay assume that treatment should primarily be medical or physical.
A team from Cardiff and Vale University Health Board is developing an innovative groupintervention for lower back pain patients, incorporating a bio-psychosocial approach.
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They will be looking at the impact of changing the first point of contact within physiotherapy for these patients from a one-to-one setting, to a fast-tracked group intervention.
The primary benefit will be patients being empowered to take a centraland active role in the management of their condition.
The aim is to deliver these group interventions in at least three Cardiff and Vale hospitals.
Primary Contact Details: George Oliver, Clinical Lead Physiotherapist, Outpatient PhysiotherapyDepartment, Longcross House, Cardiff Royal Infirmary, CF24 [email protected]
Central and North West London NHS FT: Care bundles to improve physical health care in services for people with long-term mental health needs
Physical health outcomes are unacceptably poor in people who have long-term mental health needs.
People with schizophrenia have a life expectancy that is 20 years less than the generalpopulation, and a significantly increased prevalence of physical health problems.In acute medicine, ‘care bundles’ have been extensively used as a way of implementing evidence based interventions, but they have not been extensively used in mental health care.
A team from Central and North West London NHS Foundation Trust is developing care bundles to improve implementation of key physical health care interventions for mental health patients.
The three key areas for intervention are: identification and management of physical health problems; identification of lifestyle risks and appropriate referral; and improved monitoring of medication-related risks.
The project will take place across an inpatient ward and community mental health team in North Kensington.
Primary Contact Details: Dr Bill Tiplady, Consultant Clinical Psychologist, Adult Psychology Department, Pall Mall Mental Health Centre, 150 Barlby Road, London W10 [email protected]
City and Hackney Clinical Commissioning Group: Commissioning a pilot primary care social prescription/community referral service
The relationship between patients and GPs is often over-reliant on physical health and clinical/medical interventions.
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GPs have six minutes for each consultation and do not have the time to explore all factors impacting on a patient’s health and wellbeing. Primary care teams are in an ideal position to tackle health inequalities. However, they are often unawareof the range of community assets that are available locally and how to involve patients in them.
City and Hackney Clinical Commissioning Group has commissioned Family Action to provide a social prescription assessment service in 18 surgeries across Hackney and City.
The project will target the socially isolated, over 50s, people presentingwith social issues and people with type 2 diabetes.
The aim is to improve the relationship between GPs and the localcommunity, and to improve health and wellbeing outcomes.
Primary Contact Details: Dr Patrick Hutt, City & Hackney Clinical CommissioningGroup, The Lawson Practice, 85 Nuttall Street, N1 [email protected]
Devon Partnership NHS Trust : The use of self-management techniques in patients with mild cognitive impairment
Patients with mild cognitive impairment (MCI) are at high risk of developing dementia in the future.
While no disease-modifying treatments currently exist for people with MCI, there isevidence that lifestyle changes can reduce the risk of progression to dementia.
A team from Devon Partnership NHS Trust is looking at whether the self-managementtechniques that have been shown to be effective in depression could help MCI patients.Through personal goal setting, SMART action plans and timely follow up, patients will be empowered to take a lead role in managing their own illness. The programme will help them achieve lifestyle goals and hence reduce their risk factors for developing dementia.
The intervention will be based at the Devon Memory Service and will consist ofgroup therapy courses for patients diagnosed with MCI in South Devon.
The programme will start from September 2014, with three monthfollow-ups and qualitative data collected.
Primary Contact Details: Dr David Pearce, Associate Specialist in Older Person’s Mental Health,Devon Memory Service, Oak Ward, Torbay Hospital, Lawes Bridge, Torquay TQ2 [email protected]
East London NHS Foundation Trust: I ntegrative care pathway for patients with medically unexplained symptoms
Medically unexplained symptoms (MUS) is the term used to refer to disorderswhere the patient’s physical symptoms have no medical explanation.
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MUS patients often have unmet health needs, as a result of incorrect diagnosis, and consequently ineffective treatment, despite frequent presentation at primary and secondary care services.
Existing care pathways do not meet the complex needs of this group of patients.The complicated presentations, physical symptoms and distress mean that theyrequire a care pathway and package that is both flexible and complex.
A team from East London NHS Foundation Trust is establishing an innovativecare pathway that provides a holistic primary care service. It will offeridentification, assessment, engagement and treatment to MUS patients.
The main project aims are to see a reduction in unnecessary attendances at primaryand secondary care, improved health and increased patient satisfaction.
Primary Contact Details: Professor Frank Röhricht, Consultant Psychiatrist and Clinical Director, Newham Centre for Mental Health, Glen Road, Cherry Tree Way, London E13 [email protected]
Kings College Hospital NHS Foundation Trust: Self-management support following traumatic brain injury
Following traumatic brain injury (TBI), the physical, psychological and emotional consequences are often under-acknowledged, and little support for patients exists. However, these consequences can have a significant impact on individual and family members’ quality of life.
A team at King’s College Hospital NHS Foundation Trust is working with Bridges,a social enterprise that delivers self-management support packages for peoplefollowing stroke, and are together adapting these for people with TBI.
The ‘Bridges’ package involves training multidisciplinary staff in the self-management approach, a workbook for patients, and a booklet for their family, friends or carers, to support self-efficacy.
This innovative project will implement and assess the Bridges TBI package, starting in the acute setting of a major trauma centre for the first time. It will provide proactive support following TBI, aiming to reduce emotional consequences, disruption to quality of life, use of primary care and need for onward referral.
Primary Contact Details: Dr Petra Makela, Rehabilitation Physician, Department of Neurosurgery, 4th Floor, Hambleden Wing Central, King’s College Hospital, Denmark Hill, London, SE5 [email protected]
Kings College Hospital NHS Foundation Trust : Nurse-delivered e-cognitive behaviour therapy intervention for type 1 diabetes patients
A third of people with type 1 diabetes do not achieve optimal glycaemiccontrol, despite effective medical interventions.
These patients are often referred to intensive diabetes clinics in regional
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centres, which can be a long way from the patient’s home.
Research by a team at King’s College Hospital NHS Foundation Trust found that diabetes-specific cognitive behavioural therapy (CBT) delivered face-to-face can improve glycaemic control.
The team has now translated these findings into a nurse-led CBT intervention for type 1 diabetes patients.
To overcome access difficulties, the CBT will be redesigned to bedelivered via a secure, online, instant messaging system.
Diabetes specialist nurses will be trained to deliver Diabetes Online Therapy (DOT),a course of 10 sessions of real-time CBT integrated with diabetes support.The project aims to increase access to diabetes-focused psychological care for people with poorly controlled type 1 diabetes.
Primary Contact Details: Dr Anne Doherty, Consultant Liaison Psychiatrist in Diabetes, Diabetes Department, King’s College Hospital, Denmark Hill, London SE5 [email protected]
NHS Grampion: Improving self-care and emotional wellbeing in people with type 2 diabetes
In NHS Grampian there are approximately 22,000 people with type 2 diabetes and about 45% do not achieve optimal blood glucose control.
Effectively self-managing this condition typically involves making changes to well established lifestyle habits. There are a myriad of potential barriers to improving diet and increasing activity levels. For example, research indicates that anxiety and depression are common, and are associated with higher blood glucose levels.
A multidisciplinary team in Aberdeen is developing ACT Now! – a web-based guided self-help intervention based on the principles of Acceptance and Commitment Therapy.It is hoped this innovative project will increase access to psychological support and treatment, especially for those who cannot attend centralised appointments.
The project’s aims are to improve the emotional wellbeing of adults with type 2 diabetes, and their ability to skilfully self-manage their condition (via identifying and addressing barriers to self-management).
Primary Contact Details: Dr Kirsty MacLennan, Clinical Psychologist, Diabetes Centre, David Anderson Building, Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB25 [email protected]
NHS Greater Glasgow and Clyde: Supporting and promoting independence and return to employment after an intensive care stay
Patients who have had a prolonged intensive care stay can have persistent physical, psychological and social problems after being discharged. Current outpatient approaches have no effect on improving quality of life and outcomes in these patients.
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A team from NHS Greater Glasgow and Clyde is piloting a recovery programme that emphasises education and active participation.
The programme – InSPIRE: Intensive care recovery: Supporting and PromotingIndependence and Return to Employment – involves a five-week rehabilitation andsupport programme for intensive care unit survivors and their families.
The sessions will facilitate the journey to improved health and encourage individuals to gain greater control over their health and wellbeing, as well as improve access to available community resources.
The team aim to achieve a 20% increase in employment rates and a 20% reduction in primary care use.
Primary Contact Details: Miss Joanne McPeake, Senior Staff Nurse Critical Care/Critical Care Research Nurse,Glasgow Royal Infirmary, 84 Castle Street, 4th Floor Walton Building, Room 39, Glasgow G4 [email protected]
South West London and St Georges NHS Foundation Trust : Occupational therapy intervention for people with affective and personality disorders
Adults with personality or affective disorders can have difficulty engaging in self-care, work and leisure activities.
Relapse and crisis treatment in hospital or at home disrupts daily life and impairs the ability of these patients to live independently.
Following hospital admissions, home visits are conducted but there is no routine provision of occupation-focused interventions to promote independence and self-management.
A team from South West London and St George’s Mental Health NHS Trust is testing an innovative occupational therapy intervention to enable individuals to regain independence, look after themselves and participate in their community.
The intervention, which aims to improve quality of life and mental health whilst reducing relapses and admissions, has previously been successfully used with people with psychosis.
This project will test how occupational therapy might be used more effectively in supporting individuals with personality or affective disorders.
Primary Contact Details: Mary Morley, Director of Therapies, Central OT office, Building 7, South WestLondon and St George’s Mental Health NHS Trust, Springfield University Hospital,61 Glenburnie Road, London SW17 [email protected]
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University Coventry and Warwickshire NHS Foundation Trust: Promoting a positive life experience for COPD patients
Poorly managed chronic obstructive pulmonary disorder (COPD) has a negative impact on quality of life, causing restricted mobility, and leading to social isolation and poor self-esteem.
A survey by the British Lung Foundation found that 90% of COPD patients were unable to participate in socially important activities.
A team from University Hospital Coventry and Warwickshire NHS Trust is developing a project called RIPPLE – Respiratory Innovation: Promoting a Positive Life Experience. The aim is to improve the social inclusion, and thus health and wellbeing, of people with COPD. The project will involve the delivery of community-based respiratory services which will enable patients to take a more active role in their care. The team will work with a number of partner organisations, including third sector organisations.
Primary Contact Details: Dr Colin Gelder, Consultant Respiratory Physician, Respiratory Medicine, 3rd Floor East Wing, University Hospital, Clifford Bridge Road, Walsgrave, Coventry, CV2 [email protected]
Willow Bank Community Interest Company : Developing a family-centred service through redesign, delivery and commissioning
Primary care teams focus on the prevention and treatment of ill health in individuals. However, some health conditions affect more than one family member and may be caused by the family’s social context.
Willow Bank Partnership Community Interest Company is piloting a family-based service that will allow for more ‘agile’ health care delivery. It will commission family-based interventions that have the potential to improve health outcomes and reduce health care costs.
The pilot project will involve 20 families from Willow Bank’s patient list. A ‘family negotiator’ will work with the families to understand their health situation, identify agreed goals and develop an action plan.
They will ‘micro-commission’ local services and provide ongoing support to the family.The project will personalise services to individuals within families, and enhance their capacity to adopt healthier lifestyles.
Primary Contact Details: Ian Gibson, Deputy Chief Executive, Willow Bank Partnership CIC, Willow Bank Surgery, Trentham Road, Longton, Stoke on Trent, Staffordshire, ST3 [email protected]
Worcestershire Health and Care Trust: Supporting Health And Promoting Exercise (SHAPE) programme for young people with psychosis
Young people with psychosis are more likely to die prematurely than the general population and their physical health has historically been neglected.Health interventions, where offered, are often not coordinated, not geared towards young people, and difficult to sustain.
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A team from Worcestershire Health and Care NHS Trust and University of WorcesterMcClelland Wellbeing Centre are developing the SHAPE (Supporting HealthAnd Promoting Exercise) programme for young people with psychosis.
The programme will offer a coordinated, multi-professional, health and wellbeing programme to young people with psychosis, in a positive, youth-focused, socially inclusive setting.
A 12-week introductory physical health programme is a key part of the year-long intervention consisting of holistic and preventive routine health screening, access to SHAPE and 12 months’ free gym membership.
The programme is designed to address early weight gain, cardiovascular risk and metabolic disturbance, to reduce physical health inequalities and risk of premature death.
Primary Contact Details: Professor Jo Smith, Consultant Clinical Psychologist and Early Intervention Lead, Worcestershire Early Intervention Service (WEIS), 5, Merrimans Hill Road, Worcester, Worcestershire WR3 [email protected]
Co-Creating Health (ran from 2007-2012)
This programme aimed to embed self management support within mainstream health services across the UK and equip individuals and clinicians to work in partnership to achieve better outcomes.
The programme focuses on three equally important factors which determine how much individuals are able to play an active role in managing their own health:
Giving people with long term conditions the skills, confidence and support to self manage.
Helping clinicians to develop the skills, knowledge and attitude to support and motivate people with long term conditions.
Changing health systems so that they encourage and facilitate self management.
Project sites
Calderdale and Huddersfield NHS Foundation Trust Long term condition: Musculoskeletal painKey contact: Dimple Vyas, [email protected]
Cambridge University Hospitals NHS Foundation Trust Long term condition: Chronic Obstructive Pulmonary Disease (COPD)Key contact: Kate Homan, [email protected]
NHS Ayrshire & ArranLong term condition: Chronic Obstructive Pulmonary Disease (COPD)
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Key contact: Alison Anderson, [email protected]
Guy’s and St Thomas’ NHS Foundation Trust Long term condition: DiabetesKey contact: Anna Reid, [email protected]
Whittington Health Long Term condition: DiabetesKey contact: Claire Davidson, [email protected]
Torbay Care Trust & Devon Partnership TrustLong term condition: DepressionKey contact: David Pearce, [email protected]
South West London and St George’s Mental Health NHS Trust Long term condition: DepressionKey contact: Jane Street, [email protected]
Additional links
Website: http://www.health.org.uk/areas-of-work/programmes/co-creating-health/
Evaluation phase 1 and 2: http://www.health.org.uk/publications/co-creating-health-evaluation-phase-1/
http://www.health.org.uk/publications/sustaining-and-spreading-self-management-support/
Self Management Support (2013-2015)
The Health Foundation wants to continue to encourage the implementation and spread of self management support. We continued to work with four of the health economies that delivered Co-creating Health. The four sites were funded to:
1. Draw on wider approaches and learning: integrating learning with other national and international experience, including other Health Foundation programmes, wider system work on self management support and innovations such as the use of new technologies.
2. Continue to support Health Foundation learning: drawing learning from the health systems on embedding and spreading self management support and actively using this to inform policy and practice.
3. Encouraging others: provide the opportunity to engage, showcase and model to national and local leaders, influencers and peers the opportunities, challenges and approaches to embedding self management support.
The sites that are taking part in this continued learning relationship are as below:
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NHS Ayrshire and ArranKey contact: Alison Anderson, [email protected]
Whittington HealthKey contact: Claire Davidson, [email protected]
Cambridge University Hospitals NHS Foundation TrustKey contact: Kate Homan, [email protected]
Calderdale and Huddersfield NHS Foundation TrustKey contact: Dimple Vyas, [email protected]
Website link:http://www.health.org.uk/areas-of-work/programmes/spreading-self-management-support/
MAGIC (Making good decisions in collaboration) (2010-2013)
MAGIC stands for ‘making good decisions in collaboration’. MAGIC is exploring how shared decision making can be embedded in the core clinical practice of mainstream health services. A consortium of experts from Newcastle and Cardiff are putting their day-to-day efforts into running this programme. Phase 1 of the programme ran from from August 2010 until January 2012. Phase 2 of the programme which ran until the end of October 2013.
The aims and objectives of Phase 2 of the programme focused on:
Leadership and Commissioning Patient and Public Involvement Education and Training Clinical Engagement Quality Metrics and Demonstrating Value.
Links:Website: Please visit: http://www.health.org.uk/areas-of-work/programmes/shared-decision-making/the-programme/
Phase 1 evaluation:The evaluation from phase 1 can be found on our website:http://www.health.org.uk/publications/the-magic-programme-evaluation/
Key contacts:Cardiff: Maureen Fallon, [email protected]: Carole Dodd, [email protected]
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2.PublicationsOur publications present knowledge and ideas gained from our research, improvement programmes and other areas of work. All of our publications are available to download. Hard copies of many publications can also be ordered free of charge.
You can find all our publications here http://www.health.org.uk/publications. Please filter the results by ‘theme’ to see our publications on ‘Person-centred care’.
3.Person-centred care resource centrehttp://personcentredcare.health.org.uk/
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