Self Management and the Quality Strategy

Tim WarrenLong Term Conditions Unit

Scottish Government

Leading Change for the Future, June 2011Tim.warren@scotland.gsi.gov.uk

BBC RADIO 4 30th May 2011 ANALYSIS: UNHEALTHY EXPECTATIONS?

• Presenter: Michael Blastland

• John Appleby - Chief economist at the King’s Fund

• Sir John Oldham - GP & NHS clinical lead on quality and productivity

• Dr Lise Llewellyn: Chief executive of NHS Berkshire East

Demographics• OLDHAM: There is going to be a 252% rise in

the number of people with chronic diseases between now and 2050. If we take just the next four years, of the existing people with chronic diseases there’ll be a 60% rise in the number of people who have two or three conditions. On current projections of expenditure, it’s the US I think who by 2065 will spend 100% of GDP on healthcare.

• BLASTLAND: So, 100 … The whole national economy, on current projections?

• OLDHAM: Yes. US first, Japan second. We’re in the middle of the pack. That’s what I mean by the “tsunami of need”.

Rising expectations

• GLENNERSTER: I think it’s unbelievable that in twenty years time people will be prepared to accept the standards of care that people are now receiving in geriatric wards or in long-term care. I mean these will just in retrospect be considered inhuman. People are just not going to stand for that.

Sustainability

• BLASTLAND: What does that do to the NHS?

• OLDHAM: If we continue to manage people with chronic diseases as we do now, the NHS and the social care system is not sustainable. Period.

Doing things differently

• LLEWELLYN ……there’s less money to go into the NHS and it’s going to be very difficult, ….We’re going to do (manage) by doing things differently, and I think that’s what we have to work with - the public and patients - is to understand that by doing things differently, by investing in the community, by investing in prevention, actually we don’t need to have as many crises, as many admissions into hospital. But it is a difficult message.

And competitiveness• OLDHAM: 70% of our existing health and

social care costs go to help manage people with chronic diseases now. That is this minute. They account for the majority of bed days in hospital, they account for the majority of visits to GPs. Not just this country, but lots of countries. In fact I would go so far as to say that the way that a country manages the people it has with chronic diseases will be a determinant of its competitiveness as an economy because the numbers are that big and the amount of resource going into it is that big.

And Self Management• OLDHAM: I go back to that statistic at the

beginning: There is going to be a 252% rise in the number of people with chronic diseases between now and 2050. Embracing people to help manage their condition themselves is the mechanism by which we achieve their expectations.

• Your personal expectation is met by you having control over how you manage your own condition, by you pulling in the expertise as and when you need it as an individual patient. That’s the future that we need to get to - aided and abetted by technology, which I believe will start to revolutionise the way that we manage people.

And Self management• OLDHAM: I go back to that statistic at the

beginning: There is going to be a 252% rise in the number of people with chronic diseases between now and 2050. Embracing people to help manage their condition themselves is the mechanism by which we achieve their expectations.

• Your personal expectation is met by you having control over how you manage your own condition, by you pulling in the expertise as and when you need it as an individual patient. That’s the future that we need to get to - aided and abetted by technology, which I believe will start to revolutionise the way that we manage people.

Quality Strategy • Better Health Better Care development• Integrated rather than additional• Aligns policy, planning and performance• For all of us - NHS, partners and public• For the long haul

Built on people’s priorities• caring and compassionate health services

• collaborating with patients and everyone working for and with NHSScotland

• providing a clean and safe care environment

• improved access and continuity of care

• confidence and trust in healthcare services

• delivering clinical excellence

Our approach

3 Quality Ambitions• Person Centred

Mutually beneficial partnerships between patients, their families and those delivering healthcare services, which respect individual needs and values and demonstrate compassion, continuity, clear communication and shared decision-making.

• Safe

No avoidable injury or harm from the healthcare they receive, and that they are cared for in an appropriate, clean and safe environment at all times.

• Effective

The most appropriate treatments, interventions, support and services will be provided at the right time to everyone who will benefit, with no wasteful or harmful variation.

Quality Delivery Groups - roles

• 4 Delivery Groups – Safe, Person-centred, Effective and Infrastructure

• Each identifying a portfolio of high impact, aligned and coherent priorities

• Developed from existing groups where possible, and stand down a number of remaining groups

• Each to link with the other 3 Delivery Groups• System-wide coherence - support NHS Boards to

drive improvements locally – e.g. by accelerating and spreading the successful approach of SPSP

Aim Quality Delivery Groups Initial Priority Areas For Action

Scotland is a World leader in

Healthcare Quality

Person Centred

Safe

Effective

Promote Person Centred Care through 4 Action Groups• Enabling Person Centred Care• Communication and Collaboration• Improving Experience and Outcomes • Supporting Staff Experience

Deliver an agreed set of effective and efficient

interventions through 3 Action groups : • Children and Families • Improving Population Health• Reshaping Care

1. Accelerate Patient Safety Programme2. Roll out across mental health, paediatrics, and

primary care3. Integration of action to reduce occurrence of HAI

1. Communication 2. Quality Measurement Framework3. Quality HUB4. Governance5. Workforce Development6. IT/eHealth

Quality infrastructure

Quality Delivery Groups – activity

• Prioritise improvement activity which simultaneously has a high impact on quality and supports system wide cost reduction – challenging and accelerating existing programmes and identifying and filling gaps where appropriate.

• Assess impact on inequalities and on the ‘other’ 2 Quality Ambitions

• Identify requirements for infrastructure support (workforce training/skills, IT, measures, communications, HUB, governance)

• Report progress and issues to Quality Alliance Board

Quality AllianceBoard

PersonCentredDelivery Group

SafeDelivery Group

EffectiveDelivery Group

Quality Infrastructure

Delivery Group

Efficiency and Productivity

Strategic Oversight

Group

NMAHPQuality Council

Delivering Quality

inPrimary Care

National Planning Forum

Chief Executives

Health Management

Board

Quality and Efficiency

Quality Outcome Indicators

HEAT

Supporting local and national quality measures

6 Quality Outcomes

• Everyone gets the best start in life and is able to live a longer healthier life

• People are able to live well at home or in the community

• The best possible use is made of available resources

• Everyone has a positive experience of healthcare

• Staff feel supported and engaged• Healthcare is safe for every person, every

time

Reshaping Care: Scotland 65+ Health and social care expenditure (07/08 total=£4.5bn)

Other Social Work

Care Homes

Home Care

FHS

PrescribingCommunity

Other Hospital care

Emergency admissions

£1.4bn

£0.8bn£0.4bn

£0.4bn

£0.4bn

£0.3bn

£0.6bn

£0.2bn

High Performing Systems

Chris Ham: Health Economics Policy and Law 2009

Characteristics 1-5

• Ensure universal coverage• Provide care that is free at the point of delivery • Focus on prevention not just treatment• Put Primary care at the heart of delivery • Give priority to help people self manage their

conditions with support from carers and families

High Performing Systems

Characteristics 6-10

• Balance population health and personalisation

• Integrated care• Technology and IT enabled • Coordinated care • 10 characteristics linked as a strategic

approach

King’s fund report

• Self-management support can be viewed in two ways: as a portfolio of techniques and tools to help patients choose healthy behaviours; and a fundamental transformation of the patient–caregiver relationship into a collaborative partnership (De Sliva 2011, p vii).

Prevention and Self management is high priority in

Scottish Government

•Blurring lines between professionals and people – de mystifying medicine

•Blurring lines with preventative care

Moderately well controlled Moderately well controlled ---single condition single condition –– 7070--80% 80%

of LTCof LTC

Intensive Case/ Care Intensive Case/ Care ManagementManagement

Disease/ Care Disease/ Care Management Management

Population Wide Prevention, Health Improvement & Population Wide Prevention, Health Improvement & Health PromotionHealth Promotion

Targeted High Targeted High Risk Primary Risk Primary PreventionPrevention

Self Self ––Management Management

Complex coComplex co--morbidity morbidity –– 33--5% of LTC5% of LTC

Poorly controlled single Poorly controlled single condition condition –– 1515--20% of LTC20% of LTC

At high risk of At high risk of CVDCVD

33

22

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Moderately well controlled Moderately well controlled ---single condition single condition –– 7070--80% 80%

of LTCof LTC

Intensive Case/ Care Intensive Case/ Care ManagementManagement

Disease/ Care Disease/ Care Management Management

Population Wide Prevention, Health Improvement & Population Wide Prevention, Health Improvement & Health PromotionHealth Promotion

Targeted High Targeted High Risk Primary Risk Primary PreventionPrevention

Self Self ––Management Management

Complex coComplex co--morbidity morbidity –– 33--5% of LTC5% of LTC

Poorly controlled single Poorly controlled single condition condition –– 1515--20% of LTC20% of LTC

At high risk of At high risk of CVDCVD

Moderately well controlled Moderately well controlled ---single condition single condition –– 7070--80% 80%

of LTCof LTC

Intensive Case/ Care Intensive Case/ Care ManagementManagement

Disease/ Care Disease/ Care Management Management

Population Wide Prevention, Health Improvement & Population Wide Prevention, Health Improvement & Health PromotionHealth Promotion

Targeted High Targeted High Risk Primary Risk Primary PreventionPrevention

Self Self ––Management Management

Complex coComplex co--morbidity morbidity –– 33--5% of LTC5% of LTC

Poorly controlled single Poorly controlled single condition condition –– 1515--20% of LTC20% of LTC

At high risk of At high risk of CVDCVD

33

22

11

00

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Anticipatory Care

Scottish Government and LTCAS

• Strengthen role of voluntary sector

• Strategic Partnership

• Self Management Fund

• SG advised by LTCAS through representation on numerous groups

People are already self managing

But how well are we doing it?• 85% of clinicians believe they share decisions

with patients - 50% of patients believe that this is the case (Healthcare Commission and Picker)

• 60% of primary care clinicians do not endorse patients making independent judgments or acting as independent information seekers (Hibbard and Collins, 2008)

• 33% of people visiting GPs not as involved as much as they wanted to be in decision making (Healthcare Commission)

• 1 in 10 people in survey would ask Dr for clarification

• 20% not aware of treatment optionsHow Engaged are people in their Health Care? Ellins and Coulter, Picker 2005

15 min per month

= 3 hours per year

Copyright 2004 FreePhotosBank.com

Co morbidity – more than one long term condition (PTI practices, ISD)

Co-morbidity

Health conversation as marker of quality

Health conversations

• Each contact is a distillation of attitudes, empathy, experience, education, safety, service design, technology, systems working and management of resources.

• This is where self management begins, it is simply helping people to help themselves – making people aware of sources of support

The inner circle- the health conversation

• CARE measure and Approach

• Health Literacy

• Encouraging use of Teach Back

The inner circleCARE measure

• Consultation and Relational Empathy measure• Developed by Prof Stewart Mercer, funded by CSO grant• Questionnaire – 10 questions given to people after consultation• Feedback tool for staff

CARE measure How was the doctor at……

1. Making you feel at ease2. Letting you tell your “story”3. Really listening 4. Being interested in you as a whole person …5. Fully understanding your concerns

6. Showing care and compassion

7 . Being Positive8. Explaining things

clearly9. Helping you to take

control10. Making a plan of

action with you

The inner circle - the CARE Approach

Connect– Making you feel at ease, letting you tell your story

Assess– Really listening, Being interested in you as a whole-

person– Fully understanding your concerns

• Respond– Showing care and compassion, Being positive,

Explaining things clearly • Empower

– Helping you take control, Making a plan of action with you

The inner circle - Health LiteracyHealth literacy is stronger predictor of health status than

–income–employment status–education level–race or ethnic group

Report on the Council of Scientific Affairs, Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs, American Medical Association, JAMA, Feb 10, 1999

Why health literacy?

• Vital to consider literacy when developing programmes on access to health information

• 23% of adults in Scotland may have low skills1

• People with poor literacy skills have poorer health status, less knowledge of self management and health promoting behaviours

• If right for this group, will be right for all1 Adult Literacy and Numeracy in Scotland (ALNIS), Scottish Executive 2001

• “Medical authors have generally written in a foreign language; and those who were unequal to the task, have even valued themselves upon couching .. their prescriptions, in terms and characters unintelligible to the rest of mankind …Disguising medicine not only retards its improvement as a science, but exposes the profession to ridicule, and is injurious to the true interests of society… The cure of disease is doubtless a matter of great importance; but the preservation of health is of still greater … It is not to be supposed that men can be sufficiently upon their guard against diseases, who are totally ignorant of their causes.”

William Buchan “Domestic Medicine; or a Treatise on the prevention and cure of diseases by regimen and simple medicines” , Chamberlain, 9th ed Dublin 1784

William Buchan 1784

I can read it, but I don’t understand it ..

26.7 per cent may face occasional

challenges Scottish Survey of Adult Literacy, Scottish Govt August 2010

http://www.flickr.com/photos/pchweat/2331900663/

The inner circle - Teach Back

‘To be sure I’ve explained this consent form clearly, can you tell me what you are agreeing to?’’‘I want to check what we’ve discussed – can you tell me what you will tell you partner when you get home?

If information is not restated correctly, then explain again using different words, draw a diagram / simplify instructions, then use Teach back again

The outer circle Assets in Communities

• Boys Brigade

• ALISS and Trinity Academy School

• Patient Portal (Ayrshire and Arran)

• ALISS project

• Links Project

The outer circle – Boys Brigade

The outer circle - Trinity Academy

Patient PortalALISSAccess to Local Information to Support Self Management

The outer circle - ALISS workshops

• 3 workshops – Perth, Glasgow and Edinburgh

• People with long term conditions, service designers and technical experts get together to contribute ideas for improvement

Information to support self management

• NHS Inform - quality assured health information

• ALISS Access to Local Information to Support Self

Management –, citizens informing and supporting each other. Innovative project which will encourage people to create content for local resources

Key Themes from workshops

• Social isolation, loneliness• What happens post diagnosis?• Coping with everyday life• People as information hubs• Hard to find online and offline resources

Key Themes - workshops contd

• Timing of getting information

• We all communicate in different ways

• People don’t like moaning

• Support is often not condition specific (eg emotional and psychological support)

• Support is there but you don’t find it

The outer circle - Links Project

How do primary care teams connect with communities they serve?

• Signposting people to sources of support (aka social prescribing)

• ALISS Access to Local Information to Support Self Management

• Deep End initiative

The outer circle - Links Project

Information being collected in Links

• Teams feedback on current knowledge Identifying local needs (eg mental health, employment, addiction …..)

• what resources teams were aware of, used, trusted

• Learn how primary care teams and people find, understand and use local resources

• Improve connections between primary care and local communities

• Identify processes - training/time/skills required

• Report back on key learning points

Aim of Links

Method

• Short time scale – test out idea

• 6 primary care practices in Glasgow – all in deprived areas

• 4 from Fife – mix of populations

• Data collection supported by LTCC

• Clinical lead for each group

63

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The outer circle - Patient Portal

• A self management tool• Support people to manage their personal health information eg keep track of exercise, weight, blood results, mood

• Co-designed by people living with LTC

• Place to record clinical health info

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More info (on resource sheet)

www.aliss.org

ALISS Open Innovation Process(see 6 ideas and materials used)

http://alissproject.wordpress.com/