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”
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)
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.
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.