David ColinThom

1
David Colin-Thomé

• National Clinical Director for Primary Care, DH,
  England
• GP, Castlefields, Runcorn
• Honorary Visiting Professor,Centre for Public
  Policy and Management, Manchester University
• Honorary Visiting Professor, School of Health,
  University of Durham

2
Most care is self care

• The public say they are active self carers
• Over three quarters say they lead a healthy
  lifestyle (77)
• More than eight out of ten (87) say they often
  treat their minor ailment themselves
• Nearly two-thirds (64) of those who have
  recently been a hospital patient say they often
  monitor their acute illness following discharge
• Of those who have a long-term health condition,
  82 say they play an active role in caring for
  their condition themselves.
• DH/MORI survey (2005) on public attitudes towards
  self

3
Self Care across the continuum
Pure medical care Professional responsibility
Pure self care responsible individual
The Self Care Continuum
Daily choices
Self care of minor ailments
Long term conditions Shared care
Compulsory Psychiatric care
Minor ailments
Lifestyle
Acute illness
Majortrauma
Assisted care
4
Self Care Support Milestones since 1996
2002 Wanless Report puts self care at heart of
fully engaged scenario
2005 Self Care A Real Choice published
1996 Health Futures ideas generated including
self care skills training, national telephone
helpline supporting people in the community
2000 NHS Plan cites self care as one of the five
key building blocks of the future NHS
2004 NHS Improvement Plan has self care in one of
the new National Standards (D10)
1997 the New NHS White Paper commits to
supporting people to care better for themselves
2006 Our health.. White Paper Supporting
people with long term conditions to self care
published
2001 Expert Patients Programme initiated by
the DH
1998 NHS Direct helpline launched
2003 CNO made DH Director for Self Care
2004 Choosing Health White Paper plans health
trainers
2006
1996
2001
5
THE NHS, IN COMMON WITH HEALTHCARE SYSTEMS
WORLDWIDE, FACES AN INCREASING CHALLENGE IN
TREATING THOSE WITH LONG TERM CONDITIONS
INCIDENCE OF LONG TERM CONDITIONS
IMPACT ON NHS RESOURCES

• Long term conditions (LTCs) are conditions which
  current medical interventions can only control
  not cure. Common conditions include diabetes,
  asthma, and arthritis
• There are over 15 million people in England with
  longer term health needs
• The proportion of over 65s living with a chronic
  condition has risen from 48 in 1972, to 62 in
  2002

• Around 80 of GP consultations relate to
  long-term conditions
• Care of long-term conditions accounts for 60 of
  bed days in hospitals
• Two thirds of patients admitted as medical
  emergencies have an exacerbation of a long term
  condition

Source DH publication Chronic Care Compendium
DH website
6
Benefits of a first contact in primary
care.(Starfield)

• Higher patient satisfaction with health services
• Lower overall HS expenditure
• Better population health indicators
• Fewer drugs prescribed per head of population
• The higher the number of family physicians the
  lower the hospitalisation rate.

7
General Practice(Roland and Wilson)
We identify three areas in which British general
practice performs well, leading both
international policy analysts and the public to
their favourable conclusions Equity
Quality Efficiency and three important
characteristics that contribute to this
success Co-ordination Continuity
Comprehensiveness
8
LTC

• 50 of people with LTCs have not been told about
  treatment options
• 25 do not have care plan
• 50 medicines are not taken as intended.
• AND 50 do not have a self care plan

9
(No Transcript)
10
H?UR BY H?UR CARE ?F DIABETES
11
Some other DH self care support milestones

• Self care covered in National Service Frameworks
  and in DH supported programmes like DAFNE
  DESMOND for diabetes
• Self care support a core component in the policy
  for care of people with long term conditions
• Self care promoted in the new GMS contract, e.g.
  WiPP
• Self care promoted in new community pharmacy
  contract and in expansion of over the counter
  (OTC) medicines, e.g. statins
• Get the Right Treatment campaigns
• Health promotion campaigns on smoking, exercise
  and diet

12
Activity Levels in the Whole System of Care,
England, 2004 (original 1997)
NB BOXES REPRESENT FLOWS AND NOT STOCKS (square
boxes are in exact relative proportion to the
size of flow of patients) (circle indicates size
is not known)
Ayesha Dost April 1997 updated with 2004 data
13
The integrated self care support
resource
Research and Evaluation
14
Further barriers and obstacles to self care
Gaps in professional skills and
education
Professional paternalism and unwillingness
Lack of integrated whole system approach
Lack of universal access to self care support
such as IT
Clinical risks from inappropriate use
Self care may be seen as a form of rationing
Resource barrier
Measurement of NHS performance focused on
conventional services
Expertise of peers not recognised
Professional worry about demand stimulation
15
People want to do more self care

• provided that support is made available to them
• Over nine in ten people are interested in being
  more active in self care
• More than half of people who have seen a care
  professional in the last six months say they have
  not often been encouraged to do self care
• A third say they have never been encouraged by
  the professionals to do self care
• Over three-quarters said that if they had
  guidance and support from an NHS professional
  they would be far more confident about taking
  care of their own health.
• (DH/MORI research 2005)

16
Professionals can benefit too

• Supporting self care can help professionals use
  their skills to best effect
• 39 of GP time is spent dealing with patients
  suffering from self-treatable minor ailments
• 75 of AE attendances are for minor cases

17
Benefits of supporting self care

• health and other outcomes
• increase in life expectancy
• better control over symptoms
• reduction in pain, anxiety and depression levels
• improvement in quality of life with greater
  independence
• days off work can reduce by 50
• increase in social capital
• implications for the care system
• improved quality of consultations
• visits to GPs can reduce by 40 to 69
• hospital admissions can reduce by up to 50
• hospital LOS can reduce
• number of days in hospital may decrease by up to
  80
• outpatient visits can reduce by 17 to 77
• AE visits can reduce by 54
• medication intake, e.g. steroids, reduced
• medicines utilisation is improved by 30

18
Further incentivising self care support
Clarifying the Benefits
Mechanisms

• Professional training (pdp/cpd)
• Quality and Outcome Frameworks
• Practice Based Commissioning
• Directed Enhanced Service
• Payment by Results
• National tariffs on self care support
• Direct Payment

• Develop evidence on
• reduction in demand
• freeing up of professional time and more
  appropriate use of services
• how help achieve PSA or LDP targets

19
DH commissioned programme of analysis and
research to build the evidence base

• research on self diagnostic and self monitoring
  devices, telecare and assistive technology
  initial results on DH website
• systematic review of primary studies on self care
  support networks initial results on DH website
• study of research on self care education and
  skills training initiatives initial results on DH
  website
• qualitative research and focus group work on
  views of the public on self care for people with
  long-term conditions results on DH website
• self care support in general practice AE with
  particular focus on role of GPs and other
  practitioners results on expected April 2006
• randomised control trial evaluation of the Expert
  Patients Programme results for process evaluation
  available on Uni of Manchester website results
  on RCT expected April 2006
• evaluation of the Working in Partnership self
  care projects in several Primary Care Trust areas
  results expected December 2006

20
NHS Direct a multi-format service
NHS Direct Interactive

• Telephone service launched in 1998 - now gets
  over 6 million calls a year
• Internet service NHS Direct Online launched 1999
  - gets over half a million hits a month
• Digital TV service NHS Direct Interactive covers
  60 of the population and has about one million
  page viewings a month
• and NHS Direct self care guide delivered to
  20 million homes

21
Our health, our care ,our say a new direction
for community services (www.tso.co.uk/bookshop)

• Ambition
• Enabling health, independence and well being
• Better access to GP
• Better access to community services
• Support for people with longer term needs
• Care close to home
• Ensuring reforms put people in control
• Making sure change happens

22
Self Care Support in the 2006 White Paper

• the Expert Patients Programme will increase
  capacity from 12,000 course places to over
  100,000 and investment in this initiative will be
  trebled
• plans to improve self care through assistive
  technology, health checks, health trainers and
  NHS Direct
• primary care providers with a much stronger focus
  on improving self care through both the Quality
  and Outcomes Framework and on commissioning
  services that support self care. Self care
  considered as one of the highest priorities for
  future changes to contractual arrangements.
• professional education to encourage support for
  individual empowerment and self care with a clear
  self care competency framework for staff and work
  with the professional bodies to embed self care
  in core curricula
• everyone with a long term condition and/or
  long-term need for support - and their
  carers - to routinely receive self care support
  through networks

23
Earlier Pyramid of Care
24
Paradigm Shift

• Locus of control
• Meeting of two experts