1. Supporting the Shift to Person Centred Care
Martin Routledge: Director, Coalition for Collaborative Care

2. Personalisation and Integration – A Moment of Opportunity?
NHS “Five Year Forward View” 2014 emphasised integration, personalisation & empowerment
“There is broad consensus on what the future needs to be. It is a future that empowers patients to take much more control over their own care and treatment. It is a future that dissolves the classic divide, set almost in stone since 1948, between family doctors and hospitals, between physical and mental health, between health and social care, between prevention and treatment.”

3. There is building evidence for a “win-win”
Reduced service use
Meds use improves
Able to work
more
Active and empowered person
Engage
with clinician more
Better disease management
Lifestyle improvements e.g. diet
Info
seeking
Patient Activation = confidence, skills & knowledge

4. Interventions that build people’s knowledge, skills, confidence…
Personal Health Budgets
Evaluation: cost effective, improved Quality of Life, best for high needs. POET survey show impact on carer well-being
Personalised care and support planning
Cochrane review 2015:  ”personalised care planning is a promising approach that offers the potential to provide effective help to patients, leading to better health outcomes”.
Shared Decision Making, including Patient Decision Aids
Better experience of care, some reduction in use of services, less surgery.
Self-Management Support, such as Expert Patient
Impact of behaviours, Quality of life, symptoms and better use of resources.
Not just technical information, but behaviour change

5. It’s more than medicine
A Guide to Community Based Approaches
for Health and Well-being: NHSE/PHE 2104

6. Integration and person centred care and support
The Five Year Forward View and Care Act offer the opportunity to build the integrated health and care system of the future. A connected group of locally led, centrally supported initiatives provide the chance to test, learn and spread the best ways of getting there
The Better Care Fund promotes integrating commissioning of health and social care. The Integration Pioneers started testing a range of innovative ways to deliver integrated health and social care
Building on lessons from these and other initiatives, the Five Year Forward View proposed two new programmes: New Care Models Vanguards and Integrated Personal Commissioning Programme. These two programmes are closely linked and the support teams will work closely together to ensure that support and evaluation work is coordinated.

7. But…
There is an increasing recognition of the great potential for new and better ways for people’s expertise to come together to ensure improved outcomes for people with long-term conditions.
But also frustration that the promising practice that can be seen in patches around the country is not becoming mainstream practice quickly enough.
We want to change this and work with those determined to move person-centred collaborative care from the margins, to the centre of practice and experience.

8. About C4CC – who are we?
A partnership of organisations across health and social care, community and voluntary sector
Hosted by NHS England
Launched in November 2014 with about 20 national partners
Now have 47 partners, 1800 members, 29 coproduction group members and a ‘hub’ team of 6 WTE staff

9. (Joined April 2015 - 24 partners) Wave 2 New Partners
Founding Partners
(14 partners)
Wave 1 New Partners
(Joined April partners)
Wave 2 New Partners
(Now 47 partners)
Royal College of General Practitioners
ADASS (Association of Directors of Adult Social Services)
British Heart Foundation
College of Social Work
Diabetes UK
The Health Foundation
Macmillan Cancer Support
National Voices
NESTA
NHS England
NHS IQ
Royal College of Nursing
Think Local Act Personal
Year of Care Partnerships
Age UK
ARMA (Arthritis and Musculoskeletal Alliance)
Arthritis Research UK
British Geriatrics Society
British Society for Rheumatology
Change
Chartered Society of Physiotherapists
College of Occupational Therapists
Community Development Foundation
Health Education England
In Control
Mind
National Council of Palliative Care
NHS Alliance
NICE
The Picker Institute
PCC (Primary Care Commissioning)
Royal College of Anaesthetists
Royal College of Physicians
Royal Pharmaceutical Society
Shared Lives Plus
Skills for Health
Spice
Timebanking UK
Alzheimer’s Society
Carers UK
Centre for Citizenship and Community
Community Catalysts
Faculty of Medical Leadership and Management
Royal College of Psychiatrists
Self-Care Forum
Skills for Care
Public Health England

10. What are we trying to do, how?
Significantly improve health and well-being for people with long term conditions and their carers and build equal and effective partnerships between people and professionals
Through gaining much greater traction for person centred care and support planning and “more than medicine/people powered ” approaches and the things that link and connect these with co-production central – Conversation, Community Co-production
Via – the actions of a partnership of influential national groups and organisations working in powerful co-production with people with long–term conditions and carers and a growing membership of local people, practitioners and groups
Using the levers and enablers within a developing context where prevention, personal and community capacity, integration and person centred approaches can be increasingly seen as part of the solution to challenges

11. What is our approach to change?
Action in four connected areas which builds the case for the incorporation of person centred approaches into core health and care activity and levers change by: supporting action and creating conditions:
1. Supporting Practice, People and Communities:
“Depth” activity, directly influencing and supporting significant exemplar initiatives to incorporate and demonstrate the case for person centred approaches
“Breadth” activity, supporting and building networks of people, organisations and champions – providing information, links and connections to enable them to implement person centred approaches in their communities of geography and interest
Direct support to pioneering programmes e.g. IPC, the Vanguards
Advice to places wanting to make change – where there is mutual benefit
Regional work to spread the word and spread good practice – like this; more to follow
Specific work – e.g. a regional leadership programme
Connecting people and initiatives – encouraging partnership, helping to align agendas of our partners, creating a movement through mass membership
Direct support to pioneering programmes e.g. IPC, the Vanguards
Advice to places wanting to make change – where there is mutual benefit
Regional work to spread the word and spread good practice – like this; more to follow
Specific work – e.g. a regional leadership programme
Connecting people and initiatives – encouraging partnership, helping to align agendas of our partners, creating a movement through mass membership

12. Supporting people and practice
Direct support to pioneering programmes e.g. IPC, the Vanguards
Advice to places wanting to make change – where there is mutual benefit
Regional work to spread the word and spread good practice – activity being planned with partners
Specific local initiatives – e.g. a regional leadership programme
Connecting people and initiatives – encouraging partnership, helping to align agendas of our partners, creating a movement through mass membership
We will support staff, people living with long-term conditions, their family carers and the wider community to bring about the change
We will do this by ensuring this ‘movement’ has the tools, connections and support it needs.
We are working in depth in some places and are working to connect people in networks and to others who can help.

13. Creating the conditions
Workforce development – bringing partners together to think about role of workforce, training needs et around person-centred care, community capacity bulding, co- production and commissioning
Providing powerful evidence – bringing together, influencing research, promoting, building stories or what’s possible
Identifying and pulling system levers to drive positive change in practice – national incentives, targets, barriers.

14. What is our approach to change?
2. Knowledge and evidence:
Sharing existing knowledge, resources and evidence with our partners, members and the wider public so that C4CC is educating informing and positively influencing people, organisations and policy related to person- centred care
Supporting development of evidence and knowledge which further builds and supports the case for person centred care and ensuring its effective deployment

15. What is our approach to change?
3. Workforce:
Supporting and influencing culture change across networks of professionals and disciplines
Inform and influence policy and developments in the area of professional training to ensure the incorporation of person centred care
Identify and communicate training and development needs for local level change to support action

16. What is our approach to change?
System levers:
Identify key levers including metrics and commissioning likely to drive person centred care into systems and practices and action that can be taken by partners and others
Support and influence DH and NHSE policy development work to ensure person centred approaches are a core part of developing models along with other key bodies and organisations holding key levers

17. To find out how you can join us and help make person-centred care a reality for people with long-term conditions, visit our website at: