HoC drives whole system change to make the care of people with LTCs person centred 

Really good BMJ analysis written by Year of Care pioneers Dr Simon Eaton and Dr Sue Roberts along with Bridget Turner. Highlights central importance of care and support planning and that HoC is a catalyst for local clinicians and their communities to collaborate in developing integrated whole system change. You can access the article by clicking here

HoC drives whole system change to make the care of people with LTCs person centred 

Dr Graham Kramer and Tim Warren talking about House of Care

Scottish Government’s Joint Improvement Team recently hosted a couple of WebEx webinars on House of Care. Collaborative Care and Support Planning as described by House of Care features in their Many Conditions, One life publication produced together with The Health and Social Care Alliance Academy. Click on this embedded link to access the webinar

Dr Graham Kramer and Tim Warren talking about House of Care

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.






The Case for Clinical Leadership in Supporting Self Management

IMG_2065Graham Kramer, Clinical Lead for Self Management and Health Literacy

The WHO definition of health is the state of complete physical, mental and social wellbeing. A valid criticism of this definition is that it has led to the classification of anything that threatens physical, social or mental well-being as a disease. This has resulted in the curative disease model of healthcare and tacitly shifted the expectation and responsibility of ensuring wellness on to the healthcare system. This is valid in the context of acute disease but unachievable in the situation for people living with long term conditions (LTCs). In these contexts outcomes and quality of life are as much determined by the resourcefulness and contribution of the individual and their social connections than their healthcare system.

There has been a call to redefine health as “the ability to adapt and self manage in the face of life’s physical, social and emotional challenges.” This definition recognises the importance of a new kind of healthcare system. One supporting the transition of people, previously regarded as passive recipients of healthcare, to one where they are viewed, and supported, to be the active agent in their health.

This transition is a fundamental change in the relationship between a person and their healthcare professional and represents challenges for both parties. It requires informed, engaged and empowered people but also collaboratively orientated professionals, supported to enable. It requires both parties to extend their expectations beyond the limits of the disease or deficit model to additionally embrace an asset-based approach that enables active participation and collaboration.

If this doesn’t happen, and the healthcare system perpetuates a disease-centred approach, then the resources of people will be under-utilised. This will lead to greater medicalisation, treatment, surveillance and passivity for people that overwhelms the capacity of the healthcare system. This threatens the safety and effectiveness of healthcare. Whether it improves disease-related outcomes is unclear however, it undoubtedly undermines people’s capacity to achieve their potential and their own personal goals. It seems, from both the experience of patients and their professionals, that this unsustainable state of affairs is here and now in healthcare. It is as if the disease model is crowding out the contributions of the people with those diseases. There is an urgent need to focus attention on allowing people and professionals to embrace enabling, personal outcomes- based approaches alongside the disease model. It is the willingness to cater for this wider holistic approach that defines a person centred healthcare system.

Is this new collaborative relationship between people and their professionals flourishing? In some respects it is. People continue to have high levels of trust in their professionals. Trust is essential for any successful relationship. People are possibly more empowered through greater access to information and knowledge via the Internet. The third sector are championing greater resources, greater involvement and a greater voice for people.

But how willing are professionals to cater for these enabling encounters with their patients? Are they willing to reciprocate the same level of trust as their patients have for them? Their contacts with people are brief but have a hugely significant impact, either positive or sadly negative, on improving capabilities. Even if willing they have little capacity to extend their role from doctor or nurse to one that is also coach and guide. The current system, built around the disease model, is dysfunctional in meeting the requirements of this professional shift. It struggles to provide sufficient time and continuity; it struggles to cater for people’s health literacy needs and share personalised information; it struggles to connect those in need with wider networks of help and support in the community. The resources to meet these needs must be as accessible from desktops as clinical guidelines and protocols.

Changing to a new system that lets this new relationship flourish will not happen without   strong voice and leadership from both people and professionals working collaboratively with policy makers. It is hampered by the dominance of the disease model that is driven by the loud engines of the pharmaceutical industry and clinical specialism. This culture of medicine is such that the voice of generalism and general practice (and people) is relatively mute. This has promoted restrictive guideline and target-led disease approaches that professionals are increasingly and contractually bound to.

We need to recognise that the current disease-centred model, built around the clinical management of LTCs, is inadequate, one dimensional and of poor value. It has been progressed without alignment to the capabilities of people or their professionals. Systemic change centred on the enablement of people is proven to be more wholesome, sustainable and with better personal and disease outcomes. A win-win for people and their professionals.

Until recently we lacked a clear vision as to what a new system might look like. Now, new models are emerging such as the House of Care model and the Alaskan Nuka system. We know what needs to be done and how to do it. Patients are up for it, all it needs now is the courage and leadership of professionals, supported by Health Boards and Policy, to bring in to practice the transformation to collaborative, enabling care.


The Case for Clinical Leadership in Supporting Self Management