1. Blythe Robertson Scottish Government
House of Care
Blythe Robertson
Scottish Government

4. Integrated health and social care
Palliative and EOL Care
Cancer
Diabetes Improvement Plan
Shared decision making
LTCs
Collaborative
Conversations
Self Management Support
Self Directed Support
Primary Care Transformation and New Models
Integrated health and social care

5. Basics
The House of Care has proved very memorable, providing a strong visual image for a check list, with four equally critical structural elements, protecting the conversation at the centre
Many have made use of it, and adapted it in lots of ways.
People build their own house in their own context.

7. Care & Support Planning
Organisational
Processes & Arrangements
Engaged, Informed, Empowered
Individuals
& Carers
Health & Care professional team committed to partnership working
Care & Support Planning
Conversation
‘MORE THAN MEDICINE’
Informal and formal sources of support and care
Sustained by the responsive allocation of resources

8. The purpose of support is to ensure that people have what they need to be able to live (and die) well on their own terms with their long-term condition(s).
Entwistle VA, Cribb A, Watt IS et al, Supporting people to live well with long term conditions: a brief account of a refreshed way of thinking about support for self-management. Manuscript in preparation shared 6 August 2015

10. Care & Support Planning
Organisational
Processes & Arrangements
Engaged, Informed, Empowered
Individuals
& Carers
Health & Care professional team committed to partnership working
Care & Support Planning
Conversation
‘MORE THAN MEDICINE’
Informal and formal sources of support and care
Sustained by the responsive allocation of resources

16. Organisational Processes & Arrangements
Contractual arrangements – making time IT
Recall system
Named contact
Access & communication
Organisational Processes & Arrangements
Pre-consultation results
Consultation skills
/Attitudes
INFORMAL AND FORMAL SOURCES OF SUPPORT AND CARE
sustained by the responsive allocation of resources
Collaboratively orientated healthcare professional
Engaged, Informed, Empowered
Individuals
& Carers
Health & Care professional team committed to partnership working
Care & Support Planning
Conversation
Patient access to records
Educated in SM
Shared
Correspondence
Reflective practitioners
Health & care professionals committed to partnership working
Collaboratively orientated healthcare professional
Structured education which is peer and professionally co-designed
Clinical expertise
Multidisciplinary team
‘MORE THAN MEDICINE’
Informal and formal sources of support and care
sustained by the responsive allocation of resources
Leadership from the start, right through
Recognition of Assets
Asset Mapping
ALISS
Joining people with their local assets
Individual information aggregated to inform joint strategic commissioning
Emotional
psychological support

17. Organisational Processes & Arrangements
Collaboratively orientated healthcare professional
Organisational Processes & Arrangements
Health & care professionals committed to partnership working
INFORMAL AND FORMAL SOURCES OF SUPPORT AND CARE
sustained by the responsive allocation of resources
Engaged, Informed, Empowered
Individuals
& Carers
Health & Care professional team committed to partnership working
‘MORE THAN MEDICINE’
Informal and formal sources of support and care
The centre is a dance – with the partners in that dance being the two experts in the room.
Helpfully it has Ginger on the left, who did everything that Fred did, but backwards and in high heels.

19. Half of what a person is told is forgotten¹ and half of what they remember is misunderstood²
Kessels RP. Patients’ memory for medical information. J R Soc Med. May 2003;96(5):
Anderson JL, Dodman S, Kopelman M, Fleming A. Patient information recall in a rheumatology clinic. Rheumatology. 1979;18(1):18-22.
Mismatch between professional language and jargon and the abilities of people to understand.
We assume that simply telling someone means they will understand.
My own light bulb moment Ray

20. Northwest Improvement Initiative
“The single biggest problem in communication is the illusion that it has taken place”
George Bernard Shaw
© R. Scoville & I.H.I. 31

21. The Hurdles
Modern health and social care can place daunting hurdles in our way
….We may struggle to make sense of information about our health conditions, or be unable to communicate effectively with our clinical and care staff. ……..
And this undermines our ability to manage our own conditions safely and effectively, and is a cause of health inequality.
Removing the hurdles - Making it Easy
Highlights the hidden problem of low health literacy and the impact that this has on our ability to access, understand, engage and participate in our health and social care.
Explains that low health literacy leads to poor health outcomes and widens health inequality.
Calls for all of us involved in health and social care to systematically address health literacy as a priority in our efforts to improve health and reduce health inequalities.
Sets out an ambition for all of us in Scotland to have the confidence, knowledge, understanding and skills we need to live well, with any health condition we have.

22. Care & Support Planning
Clear information provided to people
Mutually agreed upon goals
An active role for the person
Positive affect. Empathy and encouragement from professional
Care & Support Planning
Conversation

23. “I think on the ground, one of the beauties of the model is that you can actually maintain the fidelity of the programme in terms of the principles and ethos yet still have a great deal of flexibility at local level, which is a big boost for getting implementation.”
“In our practice we were moving towards this model of care anyway, so consolidating the reviews for long-term conditions because we appreciated it was very disjointed for patients, inconvenient for patients, probably didn’t make any sense to them.”

24. Care & Support Planning
Organisational
Processes & Arrangements
Engaged, Informed, Empowered
Individuals
& Carers
Health & Care professional team committed to partnership working
Care & Support Planning
Conversation
‘MORE THAN MEDICINE’
Informal and formal sources of support and care
Sustained by the responsive allocation of resources

25. Scotland’s House of Care Programme
Cath Cooney
The Health and Social Care Alliance Scotland

27. Care & Support Planning
Organisational Processes & Arrangements
Organisational Processes & Arrangements
Organisational Processes & Arrangements
Engaged, Informed, Empowered
Individuals
& Carers
Engaged, Informed, Empowered
Individuals
& Carers
Engaged, Informed, Empowered
Individuals
& Carers
Engaged, Informed, Empowered
Individuals
& Carers
Health & care professionals committed to partnership working
Health & Care professional team committed to partnership working
Health & care professionals committed to partnership working
Health & Care professional team committed to partnership working
Health & care professionals committed to partnership working
Health & Care professional team committed to partnership working
Care & Support Planning
Conversation
Care & Support Planning
Conversation
Organisational Processes & Arrangements
Health & care professionals committed to partnership working
Health & Care professional team committed to partnership working
Care & Support Planning
Conversation
Health & care professionals committed to partnership working
Health & Care professional team committed to partnership working
Care & Support Planning
Conversation
‘MORE THAN MEDICINE’
Informal and formal sources of support and care
Sustained by the responsive allocation of resources
‘MORE THAN MEDICINE’
Informal and formal sources of support and care
Sustained by the responsive allocation of resources
This is the Scottish version of the House of Care.

28. Care & Support Planning
Organisational
Processes & Arrangements
Engaged, Informed, Empowered
Individuals
& Carers
Health & Care professional team committed to partnership working
Care & Support Planning
Conversation
‘MORE THAN MEDICINE’
Informal and formal sources of support and care
Sustained by the responsive allocation of resources

29. The Care and Support Planning Process:
1st visit = Disease Surveillance Annual review tests/tasks done In between visits = PREPARATION Results/agenda setting prompts sent to patient >1 week before consultation 2nd visit = Care and Support Planning equals and experts (HCP and patient) meet to review how things are going, consider what’s important, share ideas, discuss options and develop a care plan
Informatio n
sharin g
Consultation
and joint
decision making
Agreed and
shared goals
and actions (
care plan )
gatherin g

30. *Shared Decision Making *Personal outcomes *Talking Points
Person Centred Care and Support Planning
*Health Care Conversation – which includes mental, physical & social Health
*Shared Decision Making
*Personal outcomes
*Talking Points
*Co-creating health

31. A fundamental shift in the relationship between person and professional that supports that person to be in the driving seat of their health and social care, with self-management at the heart of it

33. Helps people find and share information about local services and resources that support health and wellbeing

35. Tower Hamlets Building on the Evidence Base
72% received all 9 processes in National
Diabetes Audit: Best in England (Average 49%)
Tower Hamlets
92% of registered population (Type 2 diabetes) taking part in care planning
‘Patient perceived involvement in care’ rose from 52-82%

36. 36 Scotland Adopter Sites >50 Practices: Ayrshire & Arran,
Greater Glasgow & Clyde,
Lanarkshire, Lothian, Tayside
Gateshead (32 practices)
Gateshead (32 practices)
Hardwick (16 practices)
Improve outcomes for people with CVD & LTCs:
Implement care and support planning as routine care
Service redesign, driven by care & support planning, and including integration of cardiovascular disease services
Development and support for self-management services including third sector
Reproducible intervention (prototype):
UK National Training and Support Team
>3000 practitioners and >40 quality assured trainers 36

37. What people think about the House of Care model ...
I found this a helpful way in which to understand my condition and how I can help myself to achieve my goals
What people think about the House of Care model ...
An excellent change. Well done!
I have appreciated both visits. It’s good to see how I am doing in black and white. I left feeling helped and encouraged
Am working on decisions and solutions
I found it all good and informative, relaxed, very helpful, can only say ‘Ta’ much and will work to reach goal and priorities I set – no more Buckfast, lose a stone or more (improve diet a little and exercise more regularly) On my bike pedalling!!! All in all, cheers for a much needed, gentle boot in the BUTT?!! That’s it. Big Ken
Excellent set up. Nurse knows your health problems and I can see where help is required.
Patient experience questionnaire, Lesmahagow Nov 2016

41. Grampian and the House of Care Programme
Building the Scottish capacity for self management and asset based approaches
Strong foundation in Grampian
What support would be helpful?