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110614 tim warren presentation
The document discusses self-management of chronic conditions and its importance for sustainability of healthcare systems. It notes that: - Chronic conditions will rise dramatically, with many people having multiple conditions. - Expectations of care quality will increase as standards that are currently seen as inadequate will be viewed as inhumane. - For healthcare systems to be sustainable, chronic conditions must be managed differently by empowering self-management supported by technology and expertise when needed.
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110614 tim warren presentation
- 1. Self Management andthe Quality Strategy Tim Warren Long Term Conditions Unit Scottish Government Leading Change for the Future, June 2011 [email_address]
- 2. 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
- 3. Demographics OLDHAM: Thereis 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”.
- 4. 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.
- 5. Sustainability BLASTLAND: Whatdoes 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.
- 6. Doing things differentlyLLEWELLYN ……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.
- 7. 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.
- 8. And Self ManagementOLDHAM: 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.
- 9. And Self managementOLDHAM: 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.
- 10.
- 11. 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
- 12. Built on people’spriorities 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
- 13.
- 14. 3 Quality AmbitionsPerson 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.
- 15. 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
- 16. A im 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 Accelerate Patient Safety Programme Roll out across mental health, paediatrics, and primary care 3. Integration of action to reduce occurrence of HAI Communication Quality Measurement Framework Quality HUB Governance Workforce Development IT/eHealth Quality infrastructure
- 17. 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
- 18. Quality AllianceBoard PersonCentred Delivery Group Safe Delivery Group Effective Delivery Group Quality Infrastructure Delivery Group Efficiency and Productivity Strategic Oversight Group NMAHP Quality Council Delivering Quality in Primary Care National Planning Forum Chief Executives Health Management Board
- 19.
- 20.
- 21. 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
- 22. Reshaping Care: Scotland 65+ Health and social care expenditure (07/08 total=£4.5bn)
- 23. 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
- 24. High Performing SystemsCharacteristics 6-10 Balance population health and personalisation Integrated care Technology and IT enabled Coordinated care 10 characteristics linked as a strategic approach
- 25.
- 26. King’s fund reportSelf-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).
- 27. Prevention and Selfmanagement is high priority in Scottish Government Blurring lines between professionals and people – de mystifying medicine Blurring lines with preventative care
- 28. The aim isto delay the onset and slow the progression and impact of chronic disease The Extent and Aim of Anticipatory Care
- 29. Scottish Government andLTCAS Strengthen role of voluntary sector Strategic Partnership Self Management Fund SG advised by LTCAS through representation on numerous groups
- 30. People are alreadyself managing
- 31. But how wellare 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 options How Engaged are people in their Health Care? Ellins and Coulter, Picker 2005
- 32. 15 min permonth = 3 hours per year Copyright 2004 FreePhotosBank.com
- 33. Co morbidity –more than one long term condition (PTI practices, ISD) Co-morbidity
- 34. Health conversation asmarker of quality
- 35. Health conversations Eachcontact 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
- 36. quality alliance conversationindividual teams organisations systems health literacy consultation skills support / assets in the community policy strategy
- 37. The inner circle- the health conversation CARE measure and Approach Health Literacy Encouraging use of Teach Back
- 38. 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
- 39. CARE measure How was the doctor at…… 1. Making you feel at ease 2. 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 Positive 8. Explaining things clearly 9. Helping you to take control 10. Making a plan of action with you
- 40. 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
- 41. The inner circle- Health Literacy Health 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
- 42. Why health literacy?Vital to consider literacy when developing programmes on access to health information 23% of adults in Scotland may have low skills 1 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 all 1 Adult Literacy and Numeracy in Scotland (ALNIS), Scottish Executive 2001
- 43. “ Medical authorshave 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
- 44. I can readit, but I don’t understand it ..
- 45. 26.7 per centmay face occasional challenges Scottish Survey of Adult Literacy, Scottish Govt August 2010 http://www.flickr.com/photos/pchweat/2331900663/
- 46. 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
- 47. The outer circle Assets in Communities Boys Brigade ALISS and Trinity Academy School Patient Portal (Ayrshire and Arran) ALISS project Links Project
- 48. The outer circle– Boys Brigade
- 49. The outer circle- Trinity Academy
- 50.
- 51. Patient Portal ALISSAccess to Local Information to Support Self Management
- 52. 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
- 53. Information to supportself 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
- 54.
- 55.
- 56.
- 57. Key Themes fromworkshops Social isolation, loneliness What happens post diagnosis? Coping with everyday life People as information hubs Hard to find online and offline resources
- 58. 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
- 59. The outer circle- Links Project How do primary care teams connect with communities they serve?
- 60. Signposting people tosources of support (aka social prescribing) ALISS Access to Local Information to Support Self Management Deep End initiative The outer circle - Links Project
- 61. Information being collectedin Links Teams feedback on current knowledge Identifying local needs (eg mental health, employment, addiction …..) what resources teams were aware of, used, trusted
- 62. Learn how primarycare 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
- 63. Method Short timescale – 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
- 64. 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
- 65. More info (on resource sheet) www.aliss.org ALISS Open Innovation Process (see 6 ideas and materials used) http://alissproject.wordpress.com/
Editor's Notes
- #2 4 things: 1 quality strategy, what it is, 3 ambitions 2 SG self management programme – how it evolved 3 current sm activity 4 future ideas 4 things: 1 quality strategy, what it is, the 3 ambitions 2 SG self management programme – how it evolved 3 current sm activity 4 some ideas for future
- #12 The Quality Strategy is a development of Better Health Better Care – an extension of work that has already delivered real improvements. But we know we can make an even greater impact if we better align our policy, planning and performance activity and focus these around quality.
- #13 This is an unashamedly ambitious commitment - to provide the very best service we can for every patient every time, so that our NHS is amongst the very best in the world. In preparing for this new approach we have listened carefully to what patients, carers and people delivering healthcare services across NHSScotland - have said that they want. They want a caring and compassionate health service; they want to see real partnership between patients, clinicians and others; they want services to be provided in a clean and safe care environment, with improved access and continuity right though their journey and of course they want to have confidence in the quality and effectiveness of any treatment.
- #14 Our approach to quality is based upon the Institute of Medicine’s six dimensions of quality. These six dimensions will focus the way we measure healthcare quality to ensure we deliver the right care safely, at the right time, and in a way that is built around the particular needs of the individual
- #23 It’s helpful to look at service provision as it currently stands in cost terms. Figures for 2007/08 show us that: £4.5bn was spent in total on health and social care for people aged over 65 Nearly 2/3 of this spend was in hospital or in care homes. Emergency admissions to hospital alone accounted for 1/3 of the total spend – about £1.4bn. This huge area of unplanned/reactive activity often delivers poor outcomes for the patient and with better community provision there is scope to reduce the pressure on this area and deliver better outcomes.
- #28 Some lines about using language which is easily understood, many health care interactions are far too medical – self management is simply making sure staff and systems are capable of helping people to help themselves. Importance of not separating out anticipatory care from self management – all approaches are about helping people to help themselves, raising awareness of how best to care for themselves, manage their condition and have the confidence and knowledge to know where to get support. Developing Keep Well – Mainstreaming Keep Well, now have health and social care – better integration of healht and social care Support for the voluntary sector -
- #30 Scottish Government have developed a strategic partnership with the Long Term Conditions Alliance Scotland, which sets out agreements made between the two organisations. This is emblematic of our commitment to the voluntary sector.
- #31 Self management touches every single topic you are discussing today. The Quality Strategy focuses on person centred approaches – which is includes promoting independence and confident management of long term conditions. People living with symptoms of post polio syndrome, lymphoedema and allergy, all need to understand as much as possible what their condition is and how best to live well. What make things worse or better – action to take when there are changes in symptoms, recognising worsening – that’s all self management. Developing the knowhow on self management will come not only from health professionals, but from friends, family, internet, other people with same condition. The forum on the Scottish Post Polio Network is good example of mutual support and some hints being shared between members on sources of support.
- #33 We know from public feedback that managing alone without proper information or support is a difficult struggle. This picture shows how little time is spent with health professionals. A person with, for instance diabetes, or asthma or epilepsy will see a health professional for about 15 – 20 minutes per month, and actually - this would be pretty generous in some surgeries. This adds up to just 3 hours per year of professional contact.
- #34 There is an increasing problem with co morbidity – meaning having more than one condition, and of course chronic pain and depression are also recognised as being long term conditions. This graph from ISD shows the prevalence of comorbidy. Looking at the top bar – which is CHD. The white part of the bar shows the number of people with just CHD – just one condition, in pale blue are people with CHD plus one other condition and the dark blue is 2 or more. You will see that only 8% of people with Coronary Heart Disease only have that one condition - 67 % have CHD plus at least another 2 conditions. So these are the major reasons we are gathered here today – these graphs and population pyramids show us how important it is that our systems of caring for people get away from disease silos and separate registers. We will never be able to offer continuous, coordinated care if we organise our systems according to conditions. We need staff who are educated in the generic skills required to help people live well with long term conditions.
- #35 A few words about how we have developed self management approaches through policy and strategies. The starting off point was an acknowledgement that every health conversation reflects the health and wellbeing of our health service. Every single contact between patients and professionals is a marker of well our health system is serving our citizens. 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.
- #37 These health care contacts can be expressed like this - as inner and outer circles. The inner circle, in close to the conversation is where empathy and enablement starts. As Professor Stewart Mercer says – you don’t get enablement without empathy – they are intertwined. That is why we have supported his important work on consultation skills and the CARE measure which I will tell you more about in next few slides. A decent level of health literacy is also crucial for anyone trying to negotiate the complexities of the health and social care system – I will describe our work in health literacy. We need to ensure individuals are properly supported – but at the same time we are all supported by others – family, friends, colleagues and people in the community – our local communities are vital sources of support for us all, which can be particularly important for people living with long term conditions.
- #39 Explanation of CARE measure – patients are asked if they understood the consultation – did they get a chance to tell their story – there is link to measure is on the resource sheet
- #40 Explanation of CARE measure – patients are asked if they understood the consultation – did they get a chance to tell their story – there is link to measure is on the resource sheet
- #41 Explanation of CARE Approach – this is package being developed to support the use of the CARE measure – it is a set of workbooks and DVDs of consultations. NHS NES are inviting applicants to pilot the CARE Approach – if you are interested please see resource sheet for information.
- #42 Explanation of CARE Approach – this is package being developed to support the use of the CARE measure – it is a set of workbooks and DVDs of consultations. NHS NES are inviting applicants to pilot the CARE Approach – if you are interested please see resource sheet for information.
- #45 ALISS project’s work with local communities – adult literacy group (CLAN)
- #46 The Scottish Survey of Adult |Literacy, in August 2010, found that 26.7 of people in Scotland “may face occasional challenges”. This means that they may be able to read and write well, but not have ability to understand what they are reading. This large group of people are at great risk of not understanding their health conditions, information on medicine, treatments, procedures, completing forms, understanding appointment cards and consent forms, signage in health care settings. Many conditions require ability to understand complicated instructions – poor health literacy is an considerable risk to safety.
- #47 Teach Back is a simple method of checking understanding and is extremely useful when used appropriately in conversations about health care. Teach Back postcards being printed at the moment - will be tested out soon in Lothian Health Literacy Framework being developed as component of Person Centred Care Ambition of Quality Strategy
- #49 This 12 month project was set up as a way to engage with national youth groups. The Boys Brigade were keen to collaborate on raising awareness of self management and long term conditions. The Boys Brigade have 450 groups in Scotland and 20,000 members, aged between 12 – 18, so were a great place to start. The project has gone well – lots of activities were organised around the theme of healthy lifestyles – summer camps, games and quizzes which encouraged the boys to learn more about long term conditions. All the material developed with the BBs will be shared with other youth groups throughout Scotland.
- #50 This is the group of 4 senior pupils who developed a lesson plan about self management and long term conditions. This activity was part of the ALISS project and had a focus on local community sources of support . The team entered their ALISS project to a European competition called Comenius and really delighted to say they are through to the last round and will present their project in Bremen in Germany later this year. Meantime senior pupils will continue to use their lesson plans with junior pupils, many of whom are living with long term conditions or may be caring for someone with long term condition. Health and Wellbeing stream of C for Exc – teacher in Trinity Ac had remit
- #52 Explanation of ALISS – how do we get all of this information on this poster board collected and distributed so all of us get to hear about it? ALISS is a Scottish Government project which started off as a commitment to provide each CHP with a self management framework. It was quickly decided that another website about local information wouldn’t do – there are too many websites and places to look with associated problems of updating, duplication, not finding what you want. ALISS has developed over the last 2 years into a highly innovative project – successfully collaborating with colleagues in adult literacy groups, art colleges, schools, technical experts outside the health sector. ALISS is designed to capture less formal resources, the sort of very useful but hard to find out about sources of support which most communities have. It is an ambitious project as it is tackling a difficult problem. There were 3 workstreams in ALISS – Health Literacy, Technical Development and Communities. Compliments NHS Inform More information from www.aliss.org Explain about screencasts for further information. A working “Engine” is developed - Grampian Care Data have very helpfully contributed data to allow the team to test the technology.
- #54 And so our plans are to continue to work in close partnership with the Alliance and support their valuable contribution. Early in the new year the Scottish Government will publish a long term conditions delivery plan which will set out a set of actions which will take us further down the road of implementing the strategies. All of you will have an opportunity to contribute to the plan today - I look forward to hearing your ideas. Thank you all for your attention
- #60 Explanation of Links – 6 in deprived areas of Glasgow, 4 in Fife. Complete now but generated great interest.
- #64 Have good information about areas of relatively high cost – hospital emergency admissions and specialist community based services Need more intelligence about primary and community care – primary care team skills and knowledge and patterns of consultation
- #65 Patient Portal a pilot set up in Ayrshire and Arran – aim is to encourage people to use a self management online tool> the Portal built on good work already established in Townhead Surgery in Irvine, where patients are able to renew prescriptions, book appointments etc. Initial focus on COPD and Diabetes but now potential to spread the development over Scotland.
- #66 Thank you for the chance to speak to you all today. During this presentation , I will you a flavour of national developments long term conditions in Scotland. The term long term conditions is now being accepted world wide as a better description of the previous term chronic disease. Even in our small country – there is a fantastic amount of activity - it is a very busy arena with lots happening and dozens of excellent initiatives. I have left a resource sheet which will give you an idea of what else is happening across Scotland.