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Long Term Conditions Programme

Personalised Care
Planning
For a better quality of life
For People with Long Term Conditions
KATHRYN PADGETT
(BA, RGN, RM, RHV)
ASSISTANT DIRECTOR OF NURSING

BARNSLEY CARE SERVICES DIRECT PCT

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Aim of Presentation
• Policy Context
• What is Personalised Care Planning
• What is a Long Term Condition
• Cost to NHS
• Cost to individual (How does it feel)
• Barnsley’s Vision
• Barnsley’s Programme
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“Health is a state of complete Physical, Mental and Social

Well-being and not merely the absence of disease”
World Health Organisation
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Policy Context

Long Term Conditions Programme

Personalised Care Planning
DH Commitments
Our Health, Our Care, Our Say White Paper
Commitments:

• By 2008 we would expect everyone with both long term health and social care needs to have an integrated care plan
if they want one.

• By 2010 we would expect everyone to have a care plan

• NHS Next Stage Review “High Quality For All” (2009) and Primary and Community Care Strategy re-affirms the offer
of care plans for 15m people with a long term condition

• The Operating Framework for the NHS in England 2009-10.

Over the next 2 years, to ensure those living with a long term condition receive a high quality service to manage their
condition, everyone with a long term condition should have a “personalised care plan”
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Long Term Conditions Programme

What is personalised care planning

• Personalisation has become key concept for the future of the NHS

• Health and Social Care Systems sharing services around the needs of
individuals not the other way round NHS Plan (2000)

• Goal Setting and outcomes

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What are Long Term Conditions?

• Health problems that require ongoing management over a period of

years or decades

• They are NOT curable and last longer than 12 months

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Staggering Stats

1 INCIDENCE

Almost one in three of the English population suffer from a LTC

2 Cost to the NHS

Admission £1658
Moderate exacerbation managed by GP at home £95
Mild exacerbation – self managed £15

3 Department of Health – Summary of Self Care Impact

17% Decrease in outpatients visits

40% Decrease in number of primary care consultation
50% reduction in A & E Visits
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Economic Reality – Barnsley

• NHS Crunch
• Population – nearly ¼ million
• Rising Birth Rate
• High Level Disadvantage
• Benefits paid to those unable to work due to illness or
disability nearly twice the national average
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Self Directed Care

Our vision within Barnsley is to
Have

“People maximise their aspirations for control and

independence over their health and well-being supported
by flexible, responsive, preventative, services”.

Long Term Conditions Programme
What does it mean for the person with a LTC?
What is important to me,
what I want to do: I want to
live at home, I want to return
to work, I want to get out
more, I want more suitable
housing
I want to understand my
condition better, I didn’t
listen properly to my
doctor, I was confused
I don’t feel myself, I am
lonely, I am anxious, I feel
breathless, I feel
depressed
I want information on
how to access
benefits
I want access to a
support network
information on my condition
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I am confused by all of
the medication I have to
take
I want information on
how to get back into
education
I want reliable, trustworthy
generally
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What does it mean for the person with LTC?

How does it feel for the person:

i want the hospital staff to know

what my wishes are if I am
admitted (the process goes with
I want to plan them to the hospital) – I want them
I am scared if to know about my care plan and
my condition what to do- who they need to know certain thinkgs
deteriorates – I to contact first that really matter to me

just dial 999

No-one seems to take

I see lots of
the lead, I don’t have
professionals and Services are
confidence in them and
have to repeat my scheduled at time
that I will get the right
story over and over that are not right for
services – don’t they talk
to each other? me
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Long Term Conditions Programme

Local examples

Care Navigation

Motivational Interviewing and Coaching

Co-creating Care Plans

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HOW BARNSLEY ACHIEVE SELF DIRECTED CARE PROGRAMME

TELECARE
CARE
FALLS
NAVIGATION
PREVENTION

TELEHEALTH
PERSONALISED DOL AT
CARE PLANS HOME

PERSONAL B UNIQUE
BUDGETS CARE
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Barnsley Initiatives

• Improved access to psychological therapies

• Personalised care plans
• Telecare
• Telehealth
• Care navigation
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Long Term Conditions Programme

• “I feel that I have control over my life again”

• “It feels as if everyone is working together to help me”

• 2006/07 – 12 admissions

• 2007-08 – 2 admissions

OUTCOME SHIRLEY
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IN CONCLUSION

• More proactive approaches, supporting people to self care freeing up more time to spend on
proactive and preventive care
• Improved outcomes for patients/individuals and support for their carers and families
• Supported goals to remain health, independent and sustain or achieve social inclusion – deciding for
self
• A broader range of choice – tailored to what people want, services centred around individuals not
other way around – listening
• Empowered – more confidence to self care
• Knowing more about condition and impact upon life
• Information for choice and control
• Better management of medicines
• More joined up services, less duplication
• More support for carers
• Greater ability to work, less time off sick
• Improved mental health
• Less reliance on services – reductions in emergency admissions
• People as Assets
• Equal Partnership
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NHS PLAN 2000

The generic choice model for
people with LTC
(Dec 2007 www.dh.gov.uk)
Common Core Principles to
Support Self Care
www.skillsforhealth.org