1. Scotland’s House of Care

2. Jungle

3. The individual's perspective

4. 3 out of 8757 hours or 0.03%

5. Lots going on - Mental Health Strategy for Scotland People Powered Health & Well Being Personal outcomes Talking points Co-creating health New models of primary care NUKA Links worker programme Integration of Health and Social Care Self Directed Support Connecting people to local opportunities Social prescribing Improvement, Empowerment, Evidence, Compassion

6. Commitment 15: We will work with partners, including the Royal College of General Practitioners and Long Term Conditions Alliance Scotland, to increase local knowledge of social prescribing opportunities, including through new technologies which support resources such as the ALISS system which connects existing sources of support and makes local information easy to find. We will also raise awareness, through local health improvement networks, of the benefits of such approaches.

7. Commitment 28 We will continue to work with NHS Boards and other partners to support a range of health improvement approaches for people with severe and enduring mental illness, …….

8. An analogy- Convergent Evolution We look for helpful approaches to similar issues in similar environments, which leads to ‘creatures/solutions ’ with similar ‘body shapes/ features’.

9. Useful touchstones

10. King’s fund report Self-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).

11. King’s fund report Self-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).

12. Gaun Yersel (2008) “The partnership with the individual is central to the self management agenda” “I am the leading partner in the management of my own health”

13. People in the Driving Seat The House of Care approach to a enabling and personalised care for people with LTCs Graham Kramer Tim Warren

14. Basics The House of Care has proved very memorable and ‘sticky’, providing a strong visual image for a check list, with four equally critical structural elements, keeping a bit in the middle warm, dry and safe. Many have made use of it, and adapted it in lots of ways. People build their own house in their own context.

16. Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources and Policies Health Care Organization

17. Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources and Policies Health Care Organization QOF Decision support Biomedical

18. Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources and Policies Health Care Organization Productive Interactions

21. Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources and Policies Health Care Organization Community

22. Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources and Policies Health Care Organization Community

23. Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team 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 Collaboratively orientated healthcare professional 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 Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources and Policies Health Care Organization Community

24. 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 Collaboratively orientated healthcare professional 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. 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

26. 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

27. Values?

28. The clinical consultation between a Health Care Professional and a Person with a long term condition, is a meeting of equals and experts

29. The person with a long term condition is in charge of their own life and managing their condition(s)

30. The person with a long term condition is more likely to act upon the decisions they make themselves, rather than those made for them by a professional

31. It is my role to value the person’s psychological and social well-being just as much as their physical health

32. The collaborative care planning consultation (how the care plan is agreed) is more important than the Care Plan itself

33. 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 Collaboratively orientated healthcare professional 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

34. Story

35. Ok – what do you need to support a good conversation?

36. 36

37. 37 Engaged, Informed, Empowered Individuals & Carers Health & Care professional team committed to partnership working

41. Personal Outcomes?

42. Collaboratively orientated healthcare professional Health & care professionals committed to partnership working Collaboratively orientated healthcare professional Engaged, Informed, Empowered Individuals & Carers Health & Care professional team committed to partnership working Care & Support Planning Conversation

43. Collaboratively orientated healthcare professional Health & care professionals committed to partnership working Collaboratively orientated healthcare professional Engaged, Informed, Empowered Individuals & Carers Health & Care professional team committed to partnership working Care & Support Planning Conversation Structured education which is peer and professionally co-designed Shared Correspondence Pre-consultation results Emotional psychological support Patient access to records Recognition of Assets

44. Collaboratively orientated healthcare professional Health & care professionals committed to partnership working Collaboratively orientated healthcare professional Engaged, Informed, Empowered Individuals & Carers Health & Care professional team committed to partnership working Care & Support Planning Conversation Clinical expertise Educated in SM Reflective practitioners Consultation skills /Attitudes Multidisciplinary team Leadership from the start, right through

45. Collaboratively orientated healthcare professional Health & care professionals committed to partnership working Collaboratively orientated healthcare professional Engaged, Informed, Empowered Individuals & Carers Health & Care professional team committed to partnership working Care & Support Planning Conversation ALISS Asset Mapping Joining people with their local assets Individual information aggregated to inform joint strategic commissioning ‘MORE THAN MEDICINE’ Informal and formal sources of support and care sustained by the responsive allocation of resources

46. Collaboratively orientated healthcare professional Health & care professionals committed to partnership working Collaboratively orientated healthcare professional Engaged, Informed, Empowered Individuals & Carers Health & Care professional team committed to partnership working Care & Support Planning Conversation Named contact IT Recall system Contractual arrangements – making time Organisational Processes & Arrangements

47. 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 Collaboratively orientated healthcare professional 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 Improved Outcomes

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

49. Some comments…. I helps me make sense of a really complex world… It plays nicely with the other children in the playground… There is nothing new here….. It has given me an overview of how the system should and could work….

50. HoC useful for …..

52. ALISS Asset Mapping Joining people with their local assets Individual information aggregated to inform joint strategic commissioning 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

53. Cod on the Tyne: Mental health/multiple physical /social issues

54. Next Cook Your Fish

55. ALISS Asset Mapping Joining people with their local assets Individual information aggregated to inform joint strategic commissioning 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

56. Technical ‘handshakes’ Directories or ‘Asset Mapping groups’ Hyper local & locally relevant assets’

59. ALISS Asset Mapping Joining people with their local assets Individual information aggregated to inform joint strategic commissioning 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

60. Evidence

61. Tower Hamlets : People with HbA1c< 7.5 March 2012 - 92% care planning 9 key care processes in diabetes - best reported in England (Ave. 20%) Those with all BP, HbA1C and Cholesterol ‘controlled’ 2009 = 24% 2012 = 34%

62. ‘The new pathway is not only more patient centred but more efficient in time for both patients and health care professionals.’ (Practice team member) Productivity: Improving……. Cost per patient practice level pre YOC: £21 post YOC: £21 COPD: Admissions …………..reduced by 50% A&E attendance …………..reduced by 68% Kirklees: Improvement programme : saved £225K Tower Hamlets: Emergency admissions reduced by 15%.. saved £700K

63. Latest Multiple Conditions action plan Three ‘early adopter’ sites – GGC – Lothian – Tayside Presentation to ‘Essence of General Practice’ – Alan McDevitt, Paul Gray, Miles Mack Future investment BHF

64. Sue Roberts – Care planning Care and support planning is about enabling better conversations between people living with long term conditions (LTCs) and health care practitioners that are focussed on what matters to the individual so that support and services can be tailored for each person. It is a meeting between those with technical expertise and those with lived experience in which the person is supported to identify their priorities and goals for living their life and the actions that they and/ or the service can take to help them achieve these.

65. Sue Roberts – Care planning Because introducing care and support planning involves changes to attitudes (mindsets), skills and clinic infrastructure it is also a powerful lever for culture and systems change within teams and across the wider community. It also improves job satisfaction for health care professionals who describe it as a ‘better way to work’.

66. Care and support planning is about enabling better conversations…….. Care & Support Planning Conversation between people living with long term conditions (LTCs)……

67. and health care practitioners….. Care & Support Planning Conversation between people living with long term conditions (LTCs)……

68. It is a meeting between those with technical expertise and those with lived experience Care & Support Planning Conversation so that support and services can be tailored for each person. Care & Support Planning Conversation +

69. that are focussed on what matters to the individual Care & Support Planning Conversation so that support and services can be tailored for each person. Care & Support Planning Conversation

70. Because introducing care and support planning involves changes to attitudes (mindsets), skills and clinic infrastructure. Care & Support Planning Conversation Care & Support Planning Conversation it is also a powerful lever for culture and systems change within teams and across the wider community.

71. ‘Local’ House of Care ‘National’ supports for the House of Care Competence in care planning Provision of development support for Care Planning conversations NHS Education Scotland professional bodies, patient groups to develop National support for programme for Care planning e.g’s of level of things ‘Regional’ supports for the House of Care Collaboratively orientated healthcare professional Health & care professionals committed to partnership working Russian Community Resources and Assets (‘More than medicine’) both uncommissioned and those sustained by responsive commissioning Collaboratively orientated healthcare professional Organisational Processes & Arrangements Engaged, Informed, Empowered Individuals & Carers Health & Care professional team committed to partnership working Care & Support Planning Conversation

73. 73

74. The individual's perspective