Unlocking the House of Care


Dr Graham Kramer explains about the role and development of the House of Care to enable personalised Care and Support Planning to take place in General Practice.



This article describes why the current QOF model is inadequate to support the needs of people living with long term health problems. It represents an unfinished evolution of healthcare to one that needs to be a more holistic, person-centred  and social model. One such a model is described as the ‘House of Care’, which is a framework for improvement that supports productive care and support planning conversations between people living with long term conditions (LTCs) and their healthcare professionals. These conversations allow the coordination of care around the personal goals of individuals and their carers, leading to enhanced engagement, enablement and improved medical and personal outcomes. The House of Care is attracting growing interest amongst policy makers, GPs and specialists involved in meeting the healthcare needs of people living with LTCs.

There can’t be many GPs and practice nurses and who will be entirely comfortable with the way they manage the care of people with long term conditions. Many may see it is an industrial process of annual recalls, focused on single conditions, with checklists of financially incentivised biomedical indicators, resulting in spiralling polypharmacy and complexity. The evidence suggests that our patients are being “socialised” into passive recipients of surveillance. Whilst we annually applaud reaching the QOF payment thresholds, there is always the nagging guilt about those patients whom we haven’t engaged and have exception reported, who suffer the greatest burden of disease and complications. It doesn’t quite chime with why we became healthcare professionals.


It’s a far cry from a fully person-centred approach, where people are enabled to set their own goals, based on their unique personal circumstances. An approach where people have sufficient knowledge, understanding and skills to be the active agent in their health, in the driving seat of their care and are supported and enabled to self manage, tapping into their own innate resources and those of their community.


Making this a reality calls for a big shift in the roles that both people and their healthcare professionals traditionally play, and this can be challenging for both sides. Is such a relationship shift really necessary? The evidence suggests that it is . Where it is adopted we have seen significantly improved health and personal outcomes, along with greater satisfaction for both people and their professionals. However it is not the current reality, as 40-90% of people say they would wish to be more involved in their healthcare encounters than they are currently allowed to be. There is little evidence that that these interactions are currently taking place.



We shouldn’t feel too guilty about not attaining this holy grail of holistic, enabling care as, quite frankly, it’s impossible within the current model of community-based family practice. It requires a transformation in the way we work, an evolution towards a new model of care. Back in 2001 the Institute of Medicine recognised the huge challenge in adapting healthcare systems to embrace organised, proactive case management of people living with long term conditions. In their report, Crossing the Quality Chasm: A New Health System for the 21st Century , they said, and much cited by Dr Ed Wagner, that “current healthcare systems can’t do the job…,… trying harder will not work, …changing care systems will”

Crossing The Quality Chasm

Most of us working at the clinical coalface of healthcare will feel they are working ever harder within an the old ineffective model without a fundamental change in the healthcare system.




Prior to that report we did have evidence of what was useful to be in a new healthcare system, thanks to the prestigious work of Ed Wagner. He analysed the successful components of healthcare systems that improved outcomes for people with LTCs, and amalgamated them into what became known as The Chronic Care Model (CCM) (Fig 1)

Figure 1 The Chronic Care Model


Many clinicians working in healthcare may not know about the Chronic Care Model, but it has been driving healthcare policy for 15 years. Much attention has been given to the organisational elements of healthcare (the inner green oval above), largely driven by QOF, with the development of disease registers, active recall, clinical information systems, desk top decision support, data gathering etc. Perhaps less well known by GPs has been the significant attention given to the development, largely by third and voluntary sector organisations, of innovative and promising self management resources and policies.


Perhaps what has received least attention, certainly by policy makers, is the bit under the green ovals. This is the vital bit that clinicians and their patients are struggling with – i.e. having those productive interactions with each other. Indeed our focus on QOF (the inner green oval) is undermining those productive interactions and ability to further improve outcomes. There are also numerous challenges around knowing about, and trusting, the rich community of self management support, that connect people with ‘more than medicine.


Things seem to be changing. Due to the pioneering work which began in 2007 by Year of Care, which was led by Dr Sue Roberts and other leading diabetologists in conjunction with Diabetes UK, The Health Foundation and the then Department of Health. Firstly they looked at the pathway of care, to ensure the sharing of information, to prepare people ahead of their “productive interaction” or annual Care and Support Planning conversation. They also re-drafted Ed Wagner’s CCM into The House of Care (fig 2) which crucially puts the productive interaction at the centre of the health and care system, aligning everything else in support of that. They then developed the training and support of local grass roots clinical champions, to develop and embed care and support planning as routine, initially for people in with diabetes.

English House

Figure 2 The House of Care Coalition for Collaborative Care version from England


The House is perhaps a more memorable visual image than the CCM. It serves as both a checklist of what needs to be in place to enable care and support planning, and also as a metaphor in that if any of the structures, walls, roof and foundations, were missing it wouldn’t be complete. Importantly it seems to resonate both with policy makers and practitioners as a shared common narrative, enhancing locally developed, health and care systems that support and enable people to self manage, and to set and achieve their own goals in the context of their own life and long term health problems.


Figure 3 Scotland’s House of Care



The learning from the original Year of Care work within three localities (North Tyneside, Kirklees and Calderdale and Tower Hamlets) has been informative. Transforming care takes time and effort, particularly with the workload and contract constraints of busy General Practice. However, there was clear evidence of improved patient engagement and both practitioner and patient satisfaction. Whilst changing the care pathway was cost neutral to practices, greater success was achieved through the alignment of both existing and new investment which built on; self management support in the community, IT support, community engagement and clinical leadership. This was most notable in Tower Hamlets, with its challenging multi-ethnic population, which transformed from being in the worst 10% for achieving diabetes QOF targets in England, to having the best. It appears that by focussing on people’s personal outcomes, biomedical outcomes also improve.


The key approach of the House of Care is to enable grass roots localities to build and develop their own ‘houses’ collaboratively with people and local communities. It requires enthusiastic clinical leadership, supported by administrators and policy makers. It’s an approach which aligns with locality working and with health and social integration. This approach has been applied to people living with a variety of long term conditions and in particular those living with multiple conditions.


There’s another important dimension to Care and Support Planning and the House of Care. People are encouraged to identify their own outcomes and solutions. When this information is recorded and aggregated it allows the responsive investment and commissioning of traditional health and social care support but also non- traditional support within the community. Aligning funding according to need has addressed health inequalities in each of the pilot sites. After all, those who are greatest in need have too often been the least well served by the current model.






A New Face in the House


My name is Mhari Martin and I am delighted to be the latest addition to the House of Care team at The Health and Social Care Alliance Scotland. I am taking on the role of Evaluation and Policy Assistant and will be working alongside a talented group of individuals to implement a more person-centred approach to health and social care in Scotland. For more information about the project please see http://www.alliance-scotland.org.uk/what-we-do/projects/scotlands-house-of-care/

I have recently graduated in International Relations from St. Andrews University where I focused on human rights. I have also spent time studying Public Policy at Brown University, in the US.

I am keen to enable individuals with long term health conditions to be more involved in managing their condition and treatment. Married to a type one diabetic, I really appreciate the importance of self-management and of empowering people to achieve the best quality of life possible. I am excited to be participating in a project that could make a real difference.

With three successful early adopter sites already under way, I am looking forward to being part of the team that takes House of Care even further.

Watch this space!

A picture of me with my husband Daniel on our wedding day.
A picture of me with my husband Daniel on our wedding day.
A New Face in the House

House Tales from Tim Warren, a WebEx Virgin

hocscotlogoIt has been a funny and busy week. On Monday, I gave my first ever WebEx. It involved speaking into a phone for an hour in front of my computer, with only a tiny bit of feedback. I think it went OK, though having teased Graham Kramer regarding his ‘um’ and ‘arr’ rate, I have now discovered that this is a case of pot calling the kettle black.

I was delighted when Neil Kelly, an Annan based GP, came in with some sensible questions and a request for a copy of the information routinely sent out to people following their first visit (to get their bloods taken and feet checked) to prepare them for their second visit.

Everyone ‘who came’ stayed to the end, and you can find the a recording of the WebEx here. Graham will be hosting a re-run on the 19th February. It is fully subscribed, but you will again be able to get the recording. We plan to compare ‘polls’ afterwards.

House Tales from Tim Warren, a WebEx Virgin

Guest Post – Nick Lewis-Barned from the Year of Care Partnerships

Nick Lewis-Barned from Year of Care Partnerships reflects on Year of Care training.
This was prompted by Ross Grieve, Lead Training Consultant for the Thistle Foundation, own reflections after attending Day 1 of Year of Care training.Nick%20Lewis%20Barned

It’s probably worth saying, at the start, the House of Care approach isn’t really intended as a new system of consultation skills in the sense that Motivational Interviewing or solution focussed approaches might be. Of course the HoC can be taken at different levels, but it comes out of a biopsychosocial approach to working in partnership with (as opposed to ‘for’ or ‘at’) people with health needs. As we began to work out what was needed for this to become part of normal care, making use of all sorts of synergistic consultation models and drawing on experience of ‘what works’ (so also pretty pragmatic as regards local health systems in primary care), we identified two key dimensions:

  • The first was a process, which ‘made sense’ and in the context of which the core and more advanced communication skills could be most effective. So ‘information gathering and sharing … agenda setting … exploration and discussion … goal setting / action planning …review’ as a way of structuring a person centred approach which allows a focus to develop progressively. The skill set for this is derived from a range of theoretical and evidence based sources. This aspect is not attempting to supplant existing well founded skills or be ‘new,’ just to create an orderly approach in which they can be used effectively. In a sense this is the inside of the house;
  • The second is a recognition that effective self management means a person will be able and, where needed, supported to live well along the ‘wavy line’ -the ups and downs of everyday life. For this some specific things need to be in place within the system, not only to make the conversation between people and professionals as useful as possible, but also to help people to find their way to the resources they want and need between contacts. This is in a sense the walls, roof, foundation of the house itself.

This approach allows a way of thinking about all of the components and skills that might be needed, to identify what is already in place and what needs to be developed and also recognises where and how existing work fits together – such as the work by the Thistle Foundation. This is one of its great attractions as it means that rather than a potential competition between good programmes and projects, there is an opportunity to see how they might dovetail / enhance / complement and learn from each other.

In all of this, and absolutely critical to it, is the implicit, and at times explicit, challenge to people’s current learned attitudes (our current failing culture of healthcare). In many ways this is where much of the ‘ripple’ will happen. Once people start to think about our current paternalistic approach, and start to experience a different way of working, it makes it harder to take the more ‘traditional’ approach in other areas of clinical care, and they become more challenging of it. The “traditional” approach becomes uncomfortable and a lot less fun / effective.

Regarding follow on training, I guess this is where an effective steering group becomes really important to help a locality to identify its development and training needs and how these can be met. I’m really not sure there is a ‘one size fits all’ for this anymore than for individual patients in terms of meeting needs. It will depend on where the locality and teams start, what their capabilities, resources and skills are, what the perceived priorities are, and critically on leadership – most especially amongst clinicians (i.e. practitioner peers). Our experience is that this happens differently in different places.

In this sense the Year of Care training is indeed a starting place. Of course it would be naïve to imagine that training for 1 ½ days will automatically change everything straight away. What it can do however is help people to shift people’s perspective, identify their needs and set their individual and collective agenda for change. The YoC team is developing experience and where needed resources that people can tap into to help move things forward.

We don’t do heaps of trying out skills on day 1. I suppose this is a bit about how much material there is to cover to get people started, and a bit of a recognition that people need time to internalise things that might be quite new before ‘giving it a go’ in front of their colleagues. We actually thought lots about this when we were developing the programme in the pilot stages and found trying to get people to be too sophisticated too early didn’t work very well. So as you’ll see on day 2 there is some thinking about what has already happened in the intervening time, and then a chance to try stuff out. Some sort of reflective follow on process on skills development seems to be quite a common perceived need.

What issues do practitioners seem to grapple with? Chatting with some of our really experienced trainers, and backed up by my own experience, there are things we hear about that pose challenges to getting colleagues on side within practices; practical struggles with systems and IT; trying to work in one way with diabetes (or some other single condition) and then finding their system pushes them back to working in old ways with other long term conditions; skills for challenging situations such as people who seem disengaged or seem to want the professional to own the results or make the decisions for them; the assumption that we can only work this way with intelligent people like us and most people are incapable (not my sentiments you understand). We deal with this a bit in day 2 including thinking about what to think about with low confidence and importance ratings.

Guest Post – Nick Lewis-Barned from the Year of Care Partnerships

Info Burst

logoWe’re still finding our way with the blog, which is often the way at the start of things. Earlier today, for example, Dr Kramer sent out an email that would have worked equally well as a post on here, so I’m converting it into one. It covers a lot of useful reference material that’s all worth a read.

First up is the Holmside story, from the folks at the Year of Care partnership. It’s a really succinct summary of their experiences.

The Kings Fund has a nice critique of the House of Care from Angela Coulter available here. It’s highly illuminating reading.

The Coalition for Collaborative Care in conjunction with NHS England have produced a handbook for care and support planning which has just been released. I’m yet to dive into it, but it seems to have a good, practical focus.

Finally, the Health Foundation has a fantastic resource on Person Centred Care and Self Management, which should provide you with useful ongoing reference material.

Info Burst

A Couple of Quick News Items

actionplan_frontTwo news items to flag with you:

  • Firstly, there’s an upcoming Webex from the Joint Improvement Team, in partnership with the ALLIANCE’s Health and Social Care Academy, about the House of Care. The WebEx will be held on Monday 2 February 2015 at 10:30. It should be of interest to anyone with an interest in a truly collaborative approach to promoting health and wellbeing. Full details, here.


  • Secondly, on the not unrelated topic of Health Literacy, NES are currently advertising for a new Senior Knowledge Manager for Health Literacy. This will support, amongst other things, the Health Literacy Place. Full details are available in the job information pack. The closing date for applications is 2 February 2015.
A Couple of Quick News Items