1. Organisational Journey Supporting self-management
for people living with long-term
conditions
Organisational Journey

2. Our Journeys 2015- Next Steps 2013-2015 Continuing SMS 2010-2012
Pre-CCH
Self Mgt
Work- streams/ strategy
EPP
Health Trainers
Co-Creating Health 1
Developing p’ships
Year of Care
Implementing SMPs & ADP
Co-Creating Health 2
Sustainability & Spread
Commissioning/ 3rd Sector : NESTA
Continuing SMS
Synergies with local strategic drivers
Embedding
Good practice
Self Mgt Support Networks
More Development of P-ship Models
2015-
Next Steps
Development of
Clinical Strategies
Development of Strategies to work with Education Providers (more widely)
Building Capacity
Continuing with culture change
Commissioning
Our Journeys

3. Backdrop to our journeys
Change in NHS – Organisational and Commissioning
Policy Change – Recognition of the importance of developing services to better meet needs of people living with long-term conditions
Integrated Care Models
Better Care Fund 2013
Care Act 2014

4. Backdrop to our journeys House of Care Model
“More than medicine”
Informal and formal sources of support and care sustained by the
responsive allocation of resources

5. Progress Transformative – patient and clinician relationship
Self-Management Programmes for people living with a variety of long-term health conditions
Self-management support built into delivery models for patient services
Peer Support Groups open to patients following self-management programmes which meet regularly
Collaborative delivery with health-care professional and lay-facilitators

6. Progress Award winning programmes
Inter-professional training offered for all staff and to support whole staff teams
Training delivered to Medical Students and Specialist Registrars
Diversification of training to reach different front line staff audiences. Eg: GP Receptionists; Pharmacists.

7. Progress Self-Management Support Network
Contribution to national learning through Co-Creating Health and beyond
Recognised as National leaders in the field

8. Progress
Enabler of Strategic priorities & development of other services
Ongoing interest from national and local policy makers and commissioners

9. Enabler of integrated care
“Self management support is increasingly finding its way into peoples’ vocabulary, strategic plans and service objectives”
“This is the first time I have felt like part of an Integrated Care Organisation”
“Self Management Network and self management support work have linked different parts of the organisation that previously have had no obvious connections, and have connected to local authority and voluntary services too!”

10. Challenges Leadership & Supportive infrastructure
Building /resourcing whole-systems approach across the patch
Developing a common language across the WHOLE local economy
Outreach to whole workforce at the same time
Clear and consistent approach to supporting self-management – keeping consistent standards
Cultural shift – time and focus needed – huge numbers
Whilst all sites have some good strategic leaders and clinical / managerial leadership – it is not consistent across all parts of the system

11. Challenges Engaging Service Users Patient Power remains under-utilised
Skills /development
Maintaining capacity to deliver programmes
When Teams are to be supported, significant effort and investment can be required, for example, staff can lack confidence at the beginning of their journey; service specifications may need to change to support self-management; skills need to be practiced
Commissioning
Commissioning and securing future commitment to SMS

12. Infrastructures/ IT systems do not support shared care and support plan
NHSE care planning template
Pressure of TIME for good conversations
Organisational processes
Deprivation and low levels of activation
informed patient
Engaged,
HCP committed to partnership working
Competency framework
patient safety connection
Reinforcing new ways
My job?
Capacity -TIME
Capacity -100’s of clinicians to reach
“I’m already doing this” – “unknown unknown”
Peer support and “more than medicine”
Reaching people
1000’s of people to reach
Commissioning – The foundation
Annual funding cycle challenging to providers
Building the house with ALL providers
Scaling up; building capacity
Fragmented commissioning system/tariffs
Must review what is already being done
Didn’t develop outcome measures at the start
Move from disease specific silos

13. Key learning themes Align and integrate Engage Good leadership
Passion, belief and resilience
Work collaboratively
Understand what drives behaviour change and link to SMS
Resources in the current climate
Networking

14. Committed and respected leadership engaging the staff
Capabilities and skills to identify and solve problems
A culture hospitable and supportive of change
Resources and support to do the work of change
Data and analytics that measure and communicate impact
An enabling environment which supports and drives change
Management practices that ensure execution and implementation
Image from: Constructive comfort: accelerating change in the NHS, The Health Foundation, February

15. Practical tools & resources to help clinicians
understand and implement Person-centred care