The House of Care:
Organisational
& clinical processes
Plan
Engaged,
informed
individuals
& carers
Do
Personcentred,
coordinated
care
Act
Health & care
professionals
committed to
partnership
working
Study
Commissioning
The House of Care describes four key interdependent components that, if implemented together, will
achieve patient centred, coordinated service for people living with long term conditions and their carers.
1
Building the House –
The House of Care Toolkit
•
A framework to bring together all the relevant national guidance, published
evidence, local case studies and information for patients and their carers.
•
It includes information on what tools and resources are required to achieve
person-centred coordinated care and how these can be effectively
commissioned.
•
Resources are arranged into the four key components of the House with
summaries of the impact that could be achieved, based on current evidence
and details about where to find additional information.
To Enter the House first chose your level:
Personal
Supporting for
professionals, services
users and carers to work
together to understand, plan
and deliver person centred
coordinated care.
Local
Examples of local
examples of good practice
that will inform the
commissioning of services
at a local level .
National
National and international
guidance, evidence, tools
and resources that will
enable the construction of
the House of Care at the
next two levels.
Click on the links below for
more information about each
component and use this to
build your own house
Organisational and Clinical Processes
• Information and technology
• Care Planning
• Safety and Experience
• Guidelines, evidence and
national audits
• Care Delivery
Informed and
engaged patients
and carers
• Self management
• Information and
Technology
• Group and peer
support
• Care Planning
• Carers
Build my own
house
Person centredcoordinated care
Health and Care
Professionals
committed to
partnership
working
•
•
•
•
•
•
Integration
Culture
Workforce
Technology
Care Co-ordination
Care Planning
Commissioning
• Needs Assessment and Planning
• Joint commissioning of services
• Metrics and Evaluation
• Service User and Public Involvement
• Contracting and procurement
• Care Planning
• Tools and levers
Person centredcoordinated care
Back to house
Enables individuals to make informed decisions which are right for them, and empower them to selfcare for their long term conditions in partnership with health and care professionals. It relies on four
key components, all of which must be present for the goal, person-centred coordinated care, to be
realised
– Commissioning – which is not simply procurement but a system improvement process, the
outcomes of each cycle informing the next one.
– Engaged, informed individuals and carers – enabling individuals to self-manage and know
how to access the services they need when and where they need them.
– Organisational and clinical processes – structured around the needs of patients and
carers using the best evidence available, co-designed with service users where possible.
– Health and care professionals working in partnership – listening, supporting, and
collaborating for continuity of care.
5
Integration
Ensuring care is designed and delivered around the needs of the individual.
Integration is particularly important for people with complex care needs.
Services should be joined-up to promote improved outcomes for individuals in
need of health and social support, enabling them to live not just longer, but
better lives.
Care is planned with people who work together to understand me and my
carer(s), put me in control, co-ordinate and deliver services to achieve my
best outcomes
Back to house
Interdisciplinary working
Care Transition
Professionals from different
organisations across health and social
care and the voluntary sector working
closely together ensuring that care
feels coordinated to people living with
long term conditions and their carers.
Ensuring a seamless transition for
people with long term conditions
between different care settings.
•
•
•
•
•
Key Components
Single point of contact
Multi disciplinary team working
Professionals talk to each other
Services quick and responsive
people are promoted to stay
independent and active
Care developed around the
individual and not the system
Key Components
• Transition following discharge from
hospital
• Transition related to changes in long
term care needs
• Transition from children's to adult
services.
Health & care
professionals
committed to
partnership
working
Interdisciplinary Working
Resources
Integrated care for patients and populations: Improving outcomes by working together - A
report to the Department of Health and the NHS Future Forum, The Kings Fund
http://www.kingsfund.org.uk/publications/integrated-care-patients-and-populationsimproving-outcomes-working-together
Integrated Care and Support Pioneers programme, NHS IQ
http://www.nhsiq.nhs.uk/improvement-programmes/long-term-conditions/integratedcare.aspx
Integrated Care – Better Care Fund – Local Government Association
http://www.local.gov.uk/web/guest/health-wellbeing-and-adult-social-care//journal_content/56/10180/4096799/ARTICLE
Integrated care value case toolkit
http://www.local.gov.uk/health-wellbeing-and-adult-social-care//journal_content/56/10180/4060433/ARTICLE
ICASE - Integrated Care Support and Exchange
http://www.icase.org.uk/pg/dashboard
Kings Fund Integrated care: making it happen
http://www.kingsfund.org.uk/projects/integrated-care-making-it-happen
Back to integration
Health & care
professionals
committed to
partnership
working
Care Transition
Resources
Lost in transition, Moving young people between child and adult health
services, Royal College of Nursing
http://www.rcn.org.uk/__data/assets/pdf_file/0010/157879/003227_WEB.pdf
Transitions between children’s and adult’s health services, and the role of
voluntary and community children’s sector, VSS POLICY BREIFING
http://www.ncb.org.uk/media/42225/transition_to_adult_services_vss_briefing
.pdf
Transition, National Council for Palliative Care
http://www.ncpc.org.uk/transitions
Coordinated transition between health and social care, NICE
http://www.nice.org.uk/media/7C5/66/TranstionBetweenHealthAndSocialCare
DraftScope.pdf
Back to integration
Health & care
professionals
committed to
partnership
working
Culture
To promote an environment where people with long term conditions, their
carers and professionals involved in their care have an equal relationship
and a joint responsibility for managing their care. To ensure parity of esteem
where physical health is valued equally with mental health.
Back to house
Promoting a
partnership
approach to care
Clinical Champions
and Professional
Support
To better involve patients
in decisions about their
own health
to facilitate self-care.
Effective leadership from
professional bodies us
key to embedding the
type of culture change
that is needed.
Key Components
• Developing equal
relationships between
patients and
professionals
• Sharing information to
support patients to selfcare
•
•
•
•
Key Components
Supporting the
workforce to adjust to a
new way of working
Governance
Professional practice
Cultural relationships.
Parity of Esteem
People with poor physical
health are at higher risk of
experiencing mental health
problems and people with
poor mental health are
more likely to have poor
physical health.
Key Components
• Valuing mental health
and physical health
equally.
• Considering the physical
impact of living with a
mental health condition
and the mental health
impact of living with a
long term condition
Health & care
professionals
committed to
partnership
working
Promoting a partnership approach to care
Resources
Shared decision making, NHS England
http://www.england.nhs.uk/ourwork/pe/sdm/
Measuring Shared Decision Making A review of research evidence, NHS
Right Care
http://www.rightcare.nhs.uk/wpcontent/uploads/2012/12/Measuring_Shared_Decision_Making_Dec12.pdf
Changing the culture: resources developed by AQuA, NHS England
http://www.england.nhs.uk/ourwork/pe/sdm/resources/aqua/
Back to culture
Health & care
professionals
committed to
partnership
working
Clinical champions and professional support
Resources
Care Planning, Royal College of General Practitioners
http://www.rcgp.org.uk/clinical-and-research/clinical-resources/careplanning.aspx
6 C’s Compassion in Practice, NHS England
http://www.england.nhs.uk/nursingvision/
Health & care
professionals
committed to
partnership
working
Association for Directors of Adult Social Services
http://www.adass.org.uk/
Royal College of Nursing
https://www.rcn.org.uk/
Back to culture
Parity of Esteem
Resources
Valuing mental health equally with physical health or “Parity of Esteem”, NHS
England
http://www.england.nhs.uk/ourwork/qual-clin-lead/pe/
Long-term conditions and mental health The cost of co-morbidities, The
Kings Fund
http://www.kingsfund.org.uk/publications/long-term-conditions-and-mentalhealth?gclid=CPCbxbyoxrwCFeXKtAodh0YA4g
Mental Health Partnerships
http://mentalhealthpartnerships.com/
Back to culture
Health & care
professionals
committed to
partnership
working
Workforce
Ensuring that the workforce is configured to support partnership working both
between different professional groups and between services users and professionals
providing care. This will include considerations regarding integration of the workforce
to provide a coordinated approach to people living with long term conditions and
clarification of roles and responsibilities of professionals and opportunities for
Back to house
training.
Roles, responsibilities and
training
Integration
The long term conditions workforce should
offer a seamless pathway of care to
patients and carers. Effective workforce
integration should be in place to achieve
this.
•
•
•
•
•
Key Components
Joint training
Skill mix
Joint health and social care roles
Communication
Multi-disciplinary team working
Ensuring the workforce supporting
people living with long term conditions
are aware of the role they play and are
appropriately trained.
•
•
•
Key Components
Continuing professional
development
Person specifications
Training
Health & care
professionals
committed to
partnership
working
Integration
Resources
Integrated care for patients and populations: Improving outcomes by working
together - A report to the Department of Health and the NHS Future Forum,
The Kings Fund
http://www.kingsfund.org.uk/publications/integrated-care-patients-andpopulations-improving-outcomes-working-together
Integrated Care – Better Care Fund – Local Government Association
http://www.local.gov.uk/web/guest/health-wellbeing-and-adult-social-care//journal_content/56/10180/4096799/ARTICLE
Coordinated transition between health and social care, NICE
http://www.nice.org.uk/media/7C5/66/TranstionBetweenHealthAndSocialCare
DraftScope.pdf
Integrated Care and Support: Our Shared Commitment
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file
/198748/DEFINITIVE_FINAL_VERSION_Integrated_Care_and_Support__Our_Shared_Commitment_2013-05-13.pdf
Back to workforce
Health & care
professionals
committed to
partnership
working
Roles, responsibilities and training
Resources
Long Term Conditions, Skills for Health
http://www.skillsforhealth.org.uk/service-area/long-term-conditions/
Delivering better services for people with long-term conditions
Building the house of care, Kings Fund
http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/deliveringbetter-services-for-people-with-long-term-conditions.pdf
Back to workforce
Health & care
professionals
committed to
partnership
working
Information and Technology
Information systems and technology that facilitate equal relationships
between people with long term conditions, their carers and professionals
providing their care. This may be achieved through better access to information
or technology to allow patients to have a greater role in condition management.
Back to house
Shared information systems
Patient Held Record
Facilitating the sharing of information
between different professional groups
involved in the care of an individual to
improve the management of care.
Sharing information will aim to ensure the
wider need for the individual are
considered by all professionals involved in
their care.
The patient is given a copy of the record
to keep, and to take to health
appointments, to help manage
healthcare tasks and communication.
PHRs are formal and structured records
that are given to patients to enable the
continuity and quality of care.
•
•
Key Components
Joint care plans
Shared access or joint information
systems across health organisations
and between health and social care
Key Components
• Structured sections of patient and
healthcare information
• Blank sections to enable patient notetaking and healthcare staff notes
Health & care
professionals
committed to
partnership
working
Shared Information Systems
Resources
Technical Approaches for Sharing Care Plans, NHS QIPP Workstream
http://www.connectingforhealth.nhs.uk/systemsandservices/qipp/library/carepl
ans.pdf
Summary Care Record, Health and Social Care Information Centre
http://systems.hscic.gov.uk/scr
Health & care
professionals
committed to
partnership
working
Back to information
and technology
Patient Held Record
Resources
Summary Care Records, NHS Choices
http://www.nhs.uk/NHSEngland/thenhs/records/healthrecords/Pages/serviced
escription.aspx
Enabling patients to access electronic health records Guidance for health
professionals, Royal College of General Practitioners
http://www.rcgp.org.uk/clinical-and-research/practice-managementresources/health-informaticsgroup/~/media/Files/CIRC/Health%20Informatics%20Report.ashx
Patient record access: turning it on, sharing the learning, The Health
Foundation
http://www.health.org.uk/areas-of-work/programmes/closing-the-gap-throughchanging-relationships/related-projects/patient-record-access/
Back to information
and technology
Health & care
professionals
committed to
partnership
working
Co-ordination of care
Supporting people to better understand the health and social care system
so that they can get the support they require when they need it.
This can range from a person having a named professional as a first point of
contact with the health system to a case manager responsible for coordinating
the health and social care for people with multiple complex long term conditions.
Back to house
Case Management
Care Co-ordination
A targeted, community-based and proactive approach to care that
involves case-finding, assessment, care
planning, and care co-ordination
accurate case-finding to ensure patients
with highly complex and multiple
conditions receive high-intensity
professional support.
Supporting individuals find their way
around the, sometimes complex
services provided by health and social
care.
Key Components:
• Processes to identify those suitable
for case management are in place
• Case managers have an appropriate
case load
• Case managers are able to effectively
coordinate care
Key Components
• Care navigators
• Directory of services
• Identifying and assessing needs for
people living with long term
conditions and their carers
• Ability to identify the most appropriate
services for the individual
• Developing support plans
Health & care
professionals
committed to
partnership
working
Case Management
Resources
Case Management, What it is and how it can best be implemented, The
Kings Fund
http://www.kingsfund.org.uk/sites/files/kf/Case-Management-paper-TheKings-Fund-Paper-November-2011_0.pdf
Case management and community matrons for long term conditions, British
Medical Journal
http://www.bmj.com/content/329/7477/1251
Back to coordination of care
Health & care
professionals
committed to
partnership
working
Care Co-ordination
Resources
Safer passage: how care navigators help improve mental health services,
Health Services Journal
http://www.hsj.co.uk/resource-centre/best-practice/local-integrationresources/safer-passage-how-care-navigators-help-improve-mental-healthservices/5041420.article#
Co-ordinated care for people with complex chronic conditions, Kings Fund
http://www.kingsfund.org.uk/projects/co-ordinated-care-people-complexchronic-conditions
Care co-ordination through integrated health and social care teams, Kings
Fund
http://www.kingsfund.org.uk/projects/gp-commissioning/ten-priorities-forcommissioners/care-coordination
Back to coordination of care
Health & care
professionals
committed to
partnership
working
Care Planning
Professionals need to recognise that the personal assets that patients (and
their families) bring to the care planning process are as important as the
clinical information in the medical record. They must ensure contacts people
with long term conditions, their carers and have meet their physical, social
and emotional wellbeing needs and best support them to manage their
condition. Effective care planning requires both patients and professionals
to adequately prepared in advance and are clear about the purpose of the
care planning process.
•
•
•
•
Back to house
Care Planning
Motivational support
An interactive partnership between
clinician and patient supporting self
management .
Facilitating healthy, sustainable behaviour
change by supporting people living with
long term conditions to take a more active
role in their own care. To do this, people
require skilled support and motivation
from their clinicians.
Key Components
• Motivational interviewing techniques
• Health coaching
• Using a guiding style to engage with
patients
• Clarify strengths and aspirations, evoke
their own motivations for change, and
promote autonomy of decision making.
Key Components
Information should be given to the
patient prior to the appointment
During the appointment achievable
goals should be set in partnership.
Ongoing process
Capturing gaps between preferences
and care received and feeding back
these preferences to inform future
planning.
Health & care
professionals
committed to
partnership
working
Care planning
Resources
Shared decision making, NHS England
http://www.england.nhs.uk/ourwork/pe/sdm/
Tools for shared decision making, NHS England
http://www.england.nhs.uk/ourwork/pe/sdm/tools-sdm/
Care Planning, Royal College of General Practitioners
http://www.rcgp.org.uk/clinical-and-research/clinical-resources/careplanning.aspx
Embedding SDM in NHS care: Resources developed by Capita, NHS
England
http://www.england.nhs.uk/ourwork/pe/sdm/resources/capita/
Back to care
planning
Health & care
professionals
committed to
partnership
working
Motivational Support
Resources
Motivational Interviewing in Primary Care, Tim Anstiss
http://www.networks.nhs.uk/discussion/soapbox/130950854/232769575/motiv
ational-interviewing-in-primary-care-pdf
Motivational interviewing 1: background, principles and application in
healthcare, The Nursing Times
http://www.nursingtimes.net/motivational-interviewing-1-backgroundprinciples-and-application-in-healthcare/5018759.article
Health Coaching, NHS Direct
http://www.nhsdirect.nhs.uk/Commissioners2/HealthCoaching
Co-creating Health, Health Foundation
http://www.health.org.uk/areas-of-work/programmes/co-creating-health/
Back to care
planning
Health & care
professionals
committed to
partnership
working
Organisational and Clinical
Processes
Care Planning
The organisation of health and social care services practices should be structured to support the
care planning process. The process involves professionals working in partnership with people living
with long term conditions and their carers, identifying priorities, discussing care and support options,
agreeing goals they can achieve themselves, and co-producing a single care plan, that meets their
physical, social and emotional wellbeing needs regardless of how many long-term conditions
Back to house
they have.
Care Planning Structure
Services should to be configured to support the
ongoing collaborative care planning process.
Key Components
• Allowing time for multiple long term conditions to be
considered where required
• Allowing information on clinical test results to be
provided to the patient and the professional prior to
the care planning discussion
• Considering the frequency of appointments and
reviews to provide an opportunities to review short
and longer term goals and have mechanisms in
place for patient recall
Recording Outputs of Care Planning
Consultations
Processes are in place that allow information
captured in care planning appointments to be
recorded to inform future care planning
consultations and future service provision.
Key Components
• Information systems to records agreed goals
• Access to menus of available services to
support individuals to achieve their goals
• Information systems to record gaps between
individual preferences and services provided to
inform commissioning
Organisational and Clinical
Processes
Care Planning Structure
Resources
Partners in Care: A Guide to Implementing a Care Planning Approach to Diabetes Care, NHS
Diabetes
https://www.diabetes.org.uk/Documents/nhs-diabetes/care-planning/partners-in-careimplementing-care-planning-approach.pdf
Care Planning Improving the Lives of People with Long Term Conditions, Royal College of
General Practitioners
http://www.rcgp.org.uk/clinical-and-research/clinicalresources/~/media/Files/CIRC/Cancer/Improving%20the%20Lives%20of%20people%20with%2
0LTC%20-%202012%2005%2009.ashx
Back to care planning
Organisational and Clinical
Processes
Recording Outputs of Care Planning Consultations
Resources
Partners in Care: A Guide to Implementing a Care Planning Approach to Diabetes Care, NHS
Diabetes
https://www.diabetes.org.uk/Documents/nhs-diabetes/care-planning/partners-in-careimplementing-care-planning-approach.pdf
Back to care planning
Organisational and Clinical
Processes
Safety and Experience
People with long term conditions should receive high quality care that is safe and reliable and
that also delivers excellent patient experience. Processes should be in place to ensure patient
experience is captured and to allow safety concerns to be identified and risks for future
incidents to be reduced.
Back to house
Safety
Experience
Promoting an active safety management approach to
identify potential risk while helping to improve monitoring
and measuring of safety indicators.
Ensuring processes are in place so that the
experience of the service users can be recorded
and reviewed so that services delivered reflect the
needs and preferences of people living with long
term conditions and their carers.
•
•
•
•
•
Key Components
Evidence based procedures in place promoting safety
Potential safety concerns identified and addressed
Processes for identifying adverse incidents and near
misses
Safety concerns are freely raised and openly
discussed
Safe processes to optimise the use of medicines
Key components
• Mechanisms are in place to capture the
experiences of people living with long term
conditions and their families and carers
• These experiences inform future planning and
delivery of services
Organisational and Clinical
Processes
Safety
Resources
Patient Safety, NHS England
http://www.england.nhs.uk/ourwork/patientsafety/
European Union Network for Patient Safety and Quality of Care
http://www.pasq.eu/
Patient Safety Resource Centre, The Health Foundation
http://patientsafety.health.org.uk/?gclid=COHtiuyQ07wCFSgKwwodbj0Axg
Patient Safety, Practical information, tools and support to improve patient safety in the NHS
http://www.nrls.npsa.nhs.uk/
Medicines Optimisation: Helping patients to make the most of medicines
Good practice guidance for healthcare professionals in England, Royal Pharmaceutical Society.
http://www.rpharms.com/promoting-pharmacy-pdfs/helping-patients-make-the-most-of-their-medicines.pdf
Good practice in prescribing and managing medicines and devices, General Medical Council
http://www.gmc-uk.org/Prescribing_Guidance__2013__50955425.pdf
Back to safety and
experience
Organisational and Clinical
Processes
Experience
Resources
Improving Patient Experience, NHS England
http://www.england.nhs.uk/ourwork/pe/
6 C’s Compassion in Practice, NHS England
http://www.england.nhs.uk/nursingvision/
Transforming Patient Experience, NHS Institute
http://www.institute.nhs.uk/patient_experience/guide/the_patient_experience_research.html
Patient Experience, Kings Fund
http://www.kingsfund.org.uk/topics/patient-experience
Back to safety and
experience
Organisational and Clinical
Processes
Information and Technology
Information and technology is a key factor underpinning successful organisational
and clinical processes to support people living with long term conditions and their carers. Two
Important elements of this are how information and technology can be used to identify which
Individuals in a population will most benefit from care and to share information about these
individuals both within and between organisations.
Back to house
Risk Stratification
Information systems
Using relationships in historic population data to
estimate the future use of health care services for each
member of a population.
Professionals are required to have timely and
relevant access to information in order to effectively
manage people living with long term conditions.
Key Components
• Use of information from primary and secondary care
services in addition to social care data
• Useful both for population planning purposes and
for identifying which patients should be offered
targeted, preventive support.
Key Components
• Information sharing and access of records
across organisational boundaries
• Integrated information systems is key to ensuring
the care is delivered around the needs of the
individual as a whole.
Organisational and Clinical
Processes
Risk Stratification
Resources
Risk Stratification, NHS England
http://www.england.nhs.uk/ourwork/tsd/ig/risk-stratification/
Predicting and reducing re-admission to hospital, The Kings Fund
http://www.kingsfund.org.uk/projects/predicting-and-reducing-re-admission-hospital
RISKPROFILING AND CARE MANAGEMENT SCHEME, NHS England
http://www.england.nhs.uk/wp-content/uploads/2013/03/ess-risk-profiling.pdf
Risk Prediction Network, NHS networks
http://www.networks.nhs.uk/nhs-networks/risk-prediction-network/?searchterm=risk%20stratification
Information Governance and Risk Stratification: Advice and Options for CCGs and GPs
http://www.england.nhs.uk/wp-content/uploads/2013/06/ig-risk-ccg-gp.pdf
Advice on Risk Prediction and Stratification, London: National Information Governance Board for Health and
Social Care, July 2012 http://www.nigb.nhs.uk/pubs/guidance/riskpred.pdf
Back to information and
technology
Organisational and Clinical
Processes
Information Systems
Resources
Better information means better care, NHS England
http://www.england.nhs.uk/ourwork/tsd/care-data/
Keeping your online health and social care records safe and secure, NHS England
http://www.nhs.uk/NHSEngland/thenhs/records/healthrecords/Documents/
PatientGuidanceBooklet.pdf
New technology can improve the health services delivered to millions of people, NHS England
http://www.england.nhs.uk/2013/11/15/new-tech-imprv-hlt-serv/
Back to information and
technology
Organisational and Clinical
Processes
Guidelines, Evidence and National Audits
Ensuring the services delivered to provide person centred care for people living with long term
conditions follow the appropriate guidelines and based on robust evidence where this is available.
Back to house
Guidelines
National Audits
Evidence Based Practice
To help professionals deliver the
best possible care offering the
best value for money.
Key Components
• Independent, authoritative and
evidence-based information
• Effective ways to prevent,
diagnose and treat disease and
ill health, reducing inequalities
and variation.
• Specific diseases as well as
generic principles for care.
Audits allow health
organisations to compare their
performance against specific
standards and national trends,
enabling them to deliver better
care for their patients.
The use of robust evidence to
inform the commissioning and
delivery of services in practice.
Where evidence is not available
this may involve working with
academic institutions to
contribute to the body of
evidence available.
Key Components
• Usually conducted in disease
specific areas such as
COPD, Kidney Disease or
Stroke.
Key Components
• Routine use of evidence in
service planning and delivery
Organisational and Clinical
Processes
Guidelines
Resources
National Institute of Clinical Excellence
http://www.nice.org.uk/
Social Care Institute for Excellence
http://www.scie.org.uk/
Map of Medicine
http://www.mapofmedicine.com/
End of Life Care Quality Standard, Public Health England
http://www.endoflifecare-intelligence.org.uk/national_information_standard/
British National Formulary
http://www.bnf.org/bnf/index.htm
Back to guidelines and
national audits
Organisational and Clinical
Processes
National Audits
Resources
Clinical audits, Health and Social Care Information Centre
http://www.hscic.gov.uk/clinicalaudits
Audit and Quality Improvement, British Thoracic Society
https://www.brit-thoracic.org.uk/audit-and-quality-improvement/
Audits, University College London
http://www.ucl.ac.uk/nicor/audits
GRASP Audit Tools, PRIMIS
http://www.nottingham.ac.uk/primis/index.aspx
Back to guidelines and
national audits
Organisational and Clinical
Processes
Evidence Based Practice
Resources
NICE Evidence Search Health and Social Care, NICE
http://www.evidence.nhs.uk/
The Cochrane Library
http://www.thecochranelibrary.com/
Social Care Institute for Excellence
http://www.scie.org.uk/
Shared Learning Implementing Evidence Based Practice, NICE
http://www.nice.org.uk/usingguidance/sharedlearningimplementingniceguidance/shared_learnin
g_implementing_nice_guidance.jsp
Back to guidelines and
national audits
Organisational and Clinical
Processes
Care Delivery
How services and processes are configured to up to promote a person centred approach to
care as people with long term conditions move through the health and social care system.
This will include how to ensure care is being provided in the most clinically appropriate place
whilst paying regard to quality of life and efficiency.
Back to house
Workforce
Care Closer to Home
Rehabilitation
Ensuring workforce processes
support professionals to deliver
person centred co-ordinated
care for people living with long
term conditions.
Ensuring processes are in place
to allow people living with long
term conditions to be cared for in
a community setting where this is
clinically appropriate.
Following condition exacerbations
rehabilitation may be required to
promote recovery and prevent
further exacerbations.
Key Components
• Training of medical, nursing
allied health professionals
and social care workforce
• Consideration of the skill mix
of the workforce
Key Components
• Access to specialist clinics in
the community
• Pathways to prevent
admission and to facilitate
earlier discharge from hospital.
Key Components
• Generic rehabilitation
programmes such as social
care support to return home
safely
• Condition specific e.g. stroke or
pulmonary rehabilitation.
Organisational and Clinical
Processes
Workforce
Resources
Long Term Conditions, Skills for Health
http://www.skillsforhealth.org.uk/service-area/long-term-conditions/
Improving services for people with long-term conditions through large-scale workforce change,
NHS Employers
http://www.nhsemployers.org/SiteCollectionDocuments/Improving_services_for_people_with_lo
ng-term_conditions_through_large_scale_workforce_change_sc_140906.pdf
Long term conditions e-learning tools for NHS and social care workforce, Department of Health
https://www.gov.uk/government/news/long-term-conditions-e-learning-tools-for-nhs-and-socialcare-workforce
Back to care delivery
Organisational and Clinical
Processes
Care closer to home
Resources
Avoiding hospital admissions Lessons from evidence and experience, The Kings Fund
http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/avoiding-hospital-admissionslessons-from-evidence-experience-ham-imison-jennings-oct10.pdf
Interventions to reduce unplanned hospital admissions: a series of systematic reviews, Purdy S.
et al (June 2012)
http://www.bristol.ac.uk/primaryhealthcare/docs/projects/unplannedadmissions.pdf
Avoiding hospital admissions What does the research say? The Kings Fund
http://www.kingsfund.org.uk/sites/files/kf/Avoiding-Hospital-Admissions-Sarah-PurdyDecember2010_0.pdf
Back to care delivery
Organisational and Clinical
Processes
Rehabilitation
Resources
Pulmonary Rehabilitation, National Institute of Clinical Excellence
http://www.nice.org.uk/guidance/qualitystandards/chronicobstructivepulmonarydisease/pulmonar
yrehabilitation.jsp
Stroke Rehabilitation, National Institute of Clinical Excellence
http://guidance.nice.org.uk/CG162
Improving Patient Outcomes through restructuring Recovery, Rehabilitation and Re-ablement,
Department of Health
http://www.nhsconfed.org/Training/Documents/RRR%20redesign.pdf
Back to care delivery
Self management
Empowering people with the confidence and information to look after themselves
when they can, and visit the GP when they need to, giving people greater control
of their own health and encourages healthy behaviours that help prevent ill health
in the long-term.
Personal budgets
Engaged,
informed
individuals
and carers
Personal health budgets
are money in lieu of NHS
and social care services.
They can be spent on a
range of care and support,
including things which are
not traditionally
commissioned. They are a
tool for commissioning
services at the level of the
individual.
Key Components
• Assessment of goals for
the personal health
budget
• Agreed care plan
between the NHS and
the individual
Lifestyle
Promoting healthy lifestyle
choices for people living
with long term conditions
to ensure they experience
a good quality of life and
to reduce their likelihood of
developing further
conditions and to reduce
their impact on health and
social care service.
Key Components
• Every contact counts
• Targeted smoking
cessation services
• Weight management
services
• Exercise programmes
Back to house
Activation
Activation is a measure of
an individual’s knowledge,
skill, and confidence for
self-management. Higher
levels of activation have
been associated with
reduced healthcare
utilisation and positive
changes in self
management behaviour.
Key Components
• Assessment of the
activation levels
• Tailoring support levels
of activation
• Mechanisms to increase
activation levels
Personal Budgets
Resources
Personal health budgets, NHS England
http://www.personalhealthbudgets.england.nhs.uk
Engaged,
informed
individuals
and carers
Building on a people’s movement for change, People Hub
www.peoplehub.org.uk
Personal Health Budgets Evaluation
https://www.phbe.org.uk/
Personal Health Budgets Toolkit, NHS England
http://www.personalhealthbudgets.england.nhs.uk/Topics/Toolkit/index.cfm
Direct payments and personal budgets for social care - Commons Library Standard
Note
http://www.parliament.uk/business/publications/research/briefingpapers/SN03735/direct-payments-and-personal-budgets-for-social-care
Back to self
management
Lifestyle
Resources
Making Every Contact Count, NHS Yorkshire and Humber
http://www.makingeverycontactcount.co.uk/
Engaged,
informed
individuals
and carers
The NHS’ role in the public’s health, NHS Future Forum
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/21642
3/dh_132114.pdf
Enabling People to Live Well, The Health Foundation
http://www.health.org.uk/publications/enabling-people-to-live-well/
Self Care Forum
http://www.selfcareforum.org/
Back to self
management
Activation
Resources
Changing the culture: resources developed by AQuA, NHS England
http://www.england.nhs.uk/ourwork/pe/sdm/resources/aqua/
Engaged,
informed
individuals
and carers
Summary of the Evidence on Performance of the Patient Activation Measure (PAM),
NHS Kidney Care
http://selfmanagementsupport.health.org.uk/media_manager/public/179/SMS_resou
rce-centre_publications/PatientActivation-1.pdf
Back to self
management
Information and Technology
Information and technology is a key factor to supporting people living with
long term conditions and their carers to feel engaged with and informed
about their care. Professionals should ensure information provided is tailored
to meet the needs of the individual. Technology such has telehealth or mobile
apps can be used to give individuals independence and allow them to play
a greater role in managing their care. Technology can also be used to give
people alternative ways of accessing information, education and services.
Information
Engaged,
informed
individuals
and carers
Personalised packages of
information designed to help
people with long-term
conditions to feel more
informed and more in control
of their health and wellbeing.
Key Components
• Information on conditions,
treatments, services and
support available.
• Provision of a
personalised information
resource based on an
assessment of the
individual’s information
needs.
Telehealth and
telecare
Telecare and telehealth
services use technology to
help people live more
independently at home.
They include personal
alarms and healthmonitoring devices
Key Components
• Assessment of who will
benefit most from
telehealth/telecare
• Joint assessment and
referral process
• Service structures to
underpin telehealth and
telecare
Back to house
Digital health
In addition to telehealth
and telecare there are
other forms of technology
that can support people
living with long term
conditions and there
carers.
Key Components
• Mobile apps
• Video or internet based
consultations
• Online forums
• Social networking
• Email and text contacts
• Online education
resources
Digital Health
Resources
NHS Choices Health Apps Library, NHS Choices
http://apps.nhs.uk/
Engaged,
informed
individuals
and carers
Long Term Condition Management, Airedale Digital Healthcare Centre
http://www.airedaledigitalhealthcarecentre.nhs.uk/Long_Term_Condition_Managem
ent/
Back to
technology
Telehealth and Telecare
Resources
Telecare and telehealth technology, NHS Choices
http://www.nhs.uk/Planners/Yourhealth/Pages/Telecare.aspx
Engaged,
informed
individuals
and carers
Telehealth and telecare, The Kings Fund
http://www.kingsfund.org.uk/topics/telecare-and-telehealth
3 million lives
http://3millionlives.innovation.nhs.uk/pg/dashboard
The impact of telehealth and telecare: the Whole System Demonstrator project,
Nuffield Trust
http://www.nuffieldtrust.org.uk/our-work/projects/impact-telehealth-and-telecareevaluation-whole-system-demonstrator-project
Back to
technology
Information
Resources
Information Prescription Service, NHS Choices
http://www.nhs.uk/ipg/Pages/IPStart.aspx
NHS Choices
http://www.nhs.uk/Pages/HomePage.aspx
Engaged,
informed
individuals
and carers
Information prescriptions - an e learning tool, NHS Employers
http://www.nhsemployers.org/PlanningYourWorkforce/educationandtraining/LongTerm
Conditions/InformationPrescriptions/Pages/AboutInformationPrescriptions_Final.aspx
Getting the most out of information prescriptions, Macmillan
http://www.macmillan.org.uk/Documents/Newsletter/InfoPrescriptionsBooklet2012.pdf
Social prescribing for mental health – a guide to commissioning and delivery, Care
Services Improvement Partnership – North West
http://www.centreforwelfarereform.org/uploads/attachment/339/social-prescribing-formental-health.pdf
Back to
technology
Group and Peer support
Patients, carers and volunteer members of the public can offer opportunities to
support people living with long term conditions. This support can be offered in the
community, through groups set up specifically for this purpose or on an individual level.
Peer support is often effective as the people providing the support often have first hand
experience of living with a long term condition or caring for someone who does.
Back to house
In addition to the educational impact of courses, many patients value the social
support gained from meeting other people who are living with a long-term condition.
Engaged,
informed
individuals
and carers
Peer support groups
Lay educator
programmes
Peer-led support groups
are proven to help people
manage long-term
conditions by reducing
depression, building selfesteem and improving
physical and mental
health.
A Lay Educator is
someone who delivers
group education to people
with a long term condition
alongside a professional. A
Lay Educators may have a
long term condition, have a
family member with a long
term condition
Key Components
• Identification of
individuals willing to be
lay educators
• Development of
programmes that are
suitable for delivery by
lay educators
Key Components
• Awareness of peersupport programmes
that are available
• Peer-support groups are
considered in the care
planning process
Community health
champions
People who, with training
and support, voluntarily
bring their ability to relate
to people and their own life
experience to transform
health and well-being in
their communities
Key Components
• Champions become
involved in community
groups/events and offer
informal support people
to join in healthy
activities
Peer Support Groups
Resources
Developing Peer Support for Long Term Conditions, The Mental Health Foundation
http://www.mentalhealth.org.uk/publications/developing-peer-support/
Engaged,
informed
individuals
and carers
The Power of Peer Support, The Health Foundation
http://www.health.org.uk/news-and-events/newsletter/the-power-of-peer-support/
Back to peer
support
Lay Educator Programmes
Resources
Lay Educator Study, The DESMOND project
http://www.desmond-project.org.uk/layeducatorstudy-273.html
Engaged,
informed
individuals
and carers
Lay educators in asthma self management: Reflections on their training and
experiences, Clare Brown a, Jean Hennings b, A.-L. Caress b, M.R. Partridge
(2007)
http://ipcem.org/RESSOURCES/PDFress/Lay.pdf
Back to peer
support
Community Health Champions
Resources
Community Health Champions, Altogether better
http://www.altogetherbetter.org.uk/community-health-champions
Engaged,
informed
individuals
and carers
Community health champions: creating new relationships with patients and
communities, NHS Confederation
http://www.nhsconfed.org/Publications/Factsheets/Pages/community-healthchampions.aspx
Changing multiple health behaviours: the contribution of health trainers and
community health champions, The Kings Fund
http://www.kingsfund.org.uk/sites/files/kf/jane-south-community-health-championsposter-mar13.pdf
Back to peer
support
Care Planning
People living with long term conditions and their carers working in partnership
with professionals, identifying priorities, discussing care and support options, agreeing
goals they can achieve themselves. Co-producing a single care plan, that meets
their physical, social and emotional wellbeing needs regardless of how many
long-term conditions they have.
Back to house
Engaged,
informed
individuals
and carers
Consultation preparation
Care planning process
Research by the Health Foundation has
identified elements that can make a
consultation between patient and healthcare
professional more successful.
An ongoing process encouraging an
interactive partnership between clinician
and patient to support self management
of patients and their long term condition.
Key Components
• Receptionist conversations in general
practice
• Practice Health Champions
• Appointment guides
Key Components
• Information provided to the patient prior
to the appointment
• During the appointment achievable
goals should are set in partnership.
• Capturing gaps between preferences
and care received
• Feeding back preferences to inform
future planning.
Care Planning Process
Resources
Shared decision making, NHS England
http://www.england.nhs.uk/ourwork/pe/sdm/
Engaged,
informed
individuals
and carers
Tools for shared decision making, NHS England
http://www.england.nhs.uk/ourwork/pe/sdm/tools-sdm/
Care Planning, Royal College of General Practitioners
http://www.rcgp.org.uk/clinical-and-research/clinical-resources/care-planning.aspx
Deciding together Care planning in long term conditions, NHS Kidney Care ,
February 2013
http://www.cmkcn.nhs.uk/attachments/article/37/Deciding%20together%20%20Care
%20planning%20in%20long%20term%20conditions[1].pdf
Back to care
planning
Consultation Preparation
Resources
Right Conversation at the Right Time, The Health Foundation
http://www.rightconversation.org/
Engaged,
informed
individuals
and carers
When doctors and patients talk: making sense of the consultation, The Health
Foundation
http://www.rightconversation.org/whendoctorsandpatientstalk.pdf
Back to care
planning
Carers
There are around 6.5 million people who report that they are carers in the UK (Carers
UK, Census Analysis 2012). It is important that the health and wellbeing of carers is
considered so that they feel supported to continue to care for people living with long
term conditions.
Back to house
Engaged,
informed
individuals
and carers
Health and wellbeing of carers
Carer support and respite
Being a carer can have an impact on an
individual’s health and wellbeing. The
physical and mental health needs of carers
should be considered in addition the wider
impact on their quality of life. One key area
for consideration is financial pressure for
carers which can come from reduced
earnings and increased outgoings related to
the costs of ill health or disability.
Key Components
• Identification of the carer population and
challenges they might be facing
• Assessment and mechanisms to improve
the health and wellbeing status of carers
• Advice and signposting to services that
can support with financial and
employment pressures
Access to services which allow carers to
continue working, maintain their health and
well-being, keep families together and
ensure that carers have a life of their own
and are able and willing to continue caring
Key Components
• Consultation to understand carer
support needs
• Services offering support and respite
depending on the level of need of the
individual carer
Health and Wellbeing of Carers
Resources
Carers UK
http://www.carersuk.org/
Engaged,
informed
individuals
and carers
Looking After You, Carers UK
http://www.carersuk.org/help-and-advice/looking-after-you
Carers’ Wellbeing, NHS Choices
http://www.nhs.uk/carersdirect/yourself/Pages/Yourownwellbeinghome.aspx
Caring & Family Finances Inquiry , Carers UK
http://www.carersuk.org/get-involved/caring-family-finances-inquiry
Your Work and Career, Carers UK
http://www.carersuk.org/help-and-advice/looking-after-you/your-work-and-career
Back to carers
Carer support and respite
Resources
Carers UK
http://www.carersuk.org/
Engaged,
informed
individuals
and carers
Practical Help, Carers UK
http://www.carersuk.org/help-and-advice/practical-help
Evidence-based planning and delivery of local support for carers, Carers UK
http://www.carersuk.org/professionals/resources/practice-guides/item/3010evidence-based-planning-and-delivery-of-local-support-for-carers
Carers and the NHS practice briefing , Carers UK
http://www.carersuk.org/professionals/resources/practice-guides/item/423-carersand-the-nhs
Back to carers
Metrics and Evaluation
Information to inform commissioning processes and development of metric and outcomes that allow services
to be evaluated effectively to ensure meeting the needs of the local population.
Back to house
Information
Metric and Outcome
Development
Evaluation
Commissioners have a number of
key intelligence requirements that
need to be addressed to deliver
great commissioning.
Meaningful indicators are set so
performance management
metrics reflect the proposed
outcomes of the service whilst
being mindful of the practical
implications of measurement.
Key Components
• Development should consider
nationally set outcomes as well
as outcomes set locally.
• Consideration of how metrics
can be collected in practice
• SMART (Specific Measurable,
Attainable, Realistic, Timely)
measures are used
Evaluation should consider the
impact the service has on its
users in addition to the wider
impact on the health and social
care economy as a whole. It
should consider the economic
and activity impacts in addition to
service user experience and
health and social care outcomes
Key Components
• Evaluation criteria set in
service specifications
• Consider the if the metrics by
which services are monitored
are appropriate
Key Components
• Accurate, relevant and timely
information that enables
commissioners to design and
plan cost effective services that
will improve the quality of life for
people living with long term
conditions and their carers.
Commissioning
Information
Resources
Levels of Ambition Atlas, NHS England
http://www.england.nhs.uk/ourwork/sop/plan-sup-tools/a-atlas/
Commissioning for Value – a comprehensive data pack to support CCGs, NHS England
http://www.england.nhs.uk/resources/resources-for-ccgs/comm-for-value/
Data and knowledge gateway - Public Health England
http://datagateway.phe.org.uk/?lk_sr=govphe
Toolkit published to help improve services and close the financial gap in ‘Any town’ , NHS England
http://www.england.nhs.uk/2014/01/24/any-town/
Better data, informed commissioning, driving improved outcomes: clinical data sets
http://www.gowerplacepractice.nhs.uk/files/2013/08/View-a-list-of-codes-that-will-be-used-PDF-205kb.pdf
Statistics, NHS England
http://www.england.nhs.uk/statistics/
Back to metrics and evaly
Commissioning
Outcome and metric development
Resources
CCG outcomes indicator set
http://www.england.nhs.uk/ccg-ois/
Public Health Outcomes Framework
https://www.gov.uk/government/collections/public-health-outcomes-framework
Measurement Masterclass series for senior clinical leaders
http://www.nhsiq.nhs.uk/capacity-capability/measurement-masterclass.aspx
How to measure for improving outcomes: a guide for commissioners
http://www.kingsfund.org.uk/topics/commissioning/how-measure-improving-outcomes-guidecommissioners
Back to metrics and
evaluation
Commissioning
Evaluation
Resources
Evaluating healthcare quality improvement, The Health Foundation.
http://www.health.org.uk/publications/evaluating-healthcare-quality-improvement/
Quality and Service Improvement Tools for the NHS, NHS IQ
http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_to
ols/quality_and_service_improvement_tools_for_the_nhs.html
Approaches to Economic Evaluation in Social Care, SCIE
http://www.scie.org.uk/publications/reports/report52.pdf
Social Return on Investment
http://www.thesroinetwork.org/what-is-sroi
Back to metrics and evaluation
Commissioning
Needs Assessment and Strategic Planning
Assessment of need for people living with long term conditions and their carers across a whole health
economy, considering all health and social care needs to inform future commissioning.
Accurate, timely and relevant information for both health and social care is required to ensure to inform this
process. The outcomes of the health needs assessment process will inform strategic planning decisions
about which services should be commissioned to best meet the needs of the local population.
Needs Assessment
The process by which the need for
services and other interventions
are fully assessed. It is a vital
analysis which underpins any
strategic plan.
Key Components
• Epidemiological –information
about the area of interest and
potential interventions.
• Comparative –comparing
existing services with
established standards or with
other populations.
• Corporate – capturing the views
of stakeholders.
Strategic Planning
Planning across a local health
and social care economy,
setting priorities about what
should be commissioned to
deliver the best possible
outcomes for people living with
long term conditions.
Key Components
• Joint priority setting
• Determining which services
and pathways will be the
most appropriate to meet
local need.
Commissioning
Back to house
Reducing Inequalities
The numbers of people living with
long term conditions and the
corresponding impact they have on
health and social care is not
distributed evenly across a
population. Tackling health
inequalities is a key consideration
for commissioning services for
people living with long term
conditions
Key Components
• Identifying those at greater risk of
developing long term conditions
• Identifying those who may needs
extra support to manage their
condition(s).
Strategic Planning
Resources
Strategic and Operational Planning 2014 to 2019, NHS England
http://www.england.nhs.uk/ourwork/sop/
Wellbeing and health policy
https://www.gov.uk/government/publications/wellbeing-and-health-policy
Improving the public's health - A resource for local authorities (Dec 2013), The Kings Fund
http://www.kingsfund.org.uk/publications/improving-publics-health
Delivering better services for people with long-term conditions -Building the house of care, The Kings
Fund
http://www.kingsfund.org.uk/publications/delivering-better-services-people-long-term-conditions
Commissioning High Quality Care for People with Long Term Conditions, The Nuffield Trust
http://www.nuffieldtrust.org.uk/publications/commissioning-high-quality-care-people-long-termconditions?gclid=COTpweS3xrwCFSvHtAodG1oAVg
Back to Needs
Assessment and Planning
Commissioning
Needs Assessment
Resources
Modelling tool
http://www.local.gov.uk/web/guest/health/-/journal_content/56/10180/4060433/ARTICLE
Clustering of unhealthy behaviours over time Implications for policy and practice
http://www.kingsfund.org.uk/publications/clustering-unhealthy-behaviours-over-time
Joint Strategic Needs Assessment, NHS Confederation
http://www.nhsconfed.org/Publications/briefings/Pages/joint-strategic-needs-assessment.aspx
Joint Strategic Needs Assessment, Health and Social Care Information Centre
http://www.hscic.gov.uk/jsna
Back to Needs
Assessment and Planning
Effective Commissioning
Reducing Inequalities
Resources
Health Inequalities Gap Measurement Tool, Public Health England
http://www.sepho.org.uk/gap_intro.aspx
Health Inequalities Intervention Toolkit, Department of Health
http://www.lho.org.uk/LHO_Topics/Analytic_Tools/HealthInequalitiesInterventionToolkit.aspx
Health inequalities: concepts, frameworks and policy, NICE
http://www.nice.org.uk/niceMedia/documents/health_inequalities_concepts.pdf
Back to Needs
Assessment and Planning
Commissioning
Joint Commissioning of Services
Health and social care commissioners working together to decide what kinds of services should be
provided to local populations, who should provide them and how they should be paid for to promote
integration across health and social care. Considering long term conditions commissioning across the
whole pathway of care ensuring services are commissioned and provided according to the needs of the
individual reducing barriers imposed by organisational boundaries.
Commissioning
Responsibilities
Integrated pathway and
service development
Knowledge of the statutory
obligations of the different
organisations involved in
commissioning services.
Organisations working together to
ensure joint accountability of
outcomes across the whole system
Key Components
• Understanding “who is
responsible for what” to allow
integrated pathways to be
created and commissioned
effectively.
Colleagues across health and
social care working in partnership
to commission integrated
pathways of care meet the needs
of the individual
Key Components
• Commissioning pathways that
allow how health and social
care professionals to work
closely together to offer
seamless pathways of care
• Commissioning of services
that patients and carers feel
are well coordinated.
Commissioning
Back to house
Shared Funding
Shared funding can facilitate joint
commissioning supporting health
and social care commissioners to
work closely together to decide
together how to allocate
resources to deliver the best
outcomes across the health and
social care economy.
Key Components
• Mechanisms for sharing or
pooling resources
• Mechanisms for deciding how
Backwill
tobehouse
joint resources
allocated
Shared Funding
Resources
Integrated Care – Better Care Fund – Local Government Association
http://www.local.gov.uk/web/guest/health-wellbeing-and-adult-social-care//journal_content/56/10180/4096799/ARTICLE
Better Care Fund Planning – NHS England
http://www.england.nhs.uk/ourwork/part-rel/transformation-fund/bcf-plan/
Making best use of the Better Care Fund Spending to save? (Jan 2014)
http://www.kingsfund.org.uk/publications/making-best-use-better-care-fund
Year of Care, NHS Improving Quality
http://www.nhsiq.nhs.uk/improvement-programmes/long-term-conditions-and-integrated-care/yearof-care.aspx
Back to joint commissioning
of services
Commissioning
Commissioning Responsibilities
Resources
A framework for collaborative commissioning between clinical commissioning groups
http://www.england.nhs.uk/wp-content/uploads/2012/03/collab-commiss-frame.pdf
Commissioning fact sheet for clinical commissioning groups
http://www.england.nhs.uk/wp-content/uploads/2012/09/fs-ccg-respon.pdf
Public health commissioning in the NHS 2014 to 2015
https://www.gov.uk/government/publications/public-health-commissioning-in-the-nhs-2014-to-2015
Working together to deliver the Mandate Strengthening partnerships between the NHS and the
voluntary sector
http://www.kingsfund.org.uk/publications/working-together-deliver-mandate
Who Pays? Determining responsibility for payments to providers, August 2013, NHS England
http://www.england.nhs.uk/wp-content/uploads/2013/08/who-pays-aug13.pdf
Back to joint commissioning
of services
Commissioning
Integrated Pathway and Service Development
Resources
Winterbourne View Joint Improvement Programme, Local Government Association
http://www.local.gov.uk/web/guest/adult-social-care/-/journal_content/56/10180/3912043/ARTICLE
Integrated care for patients and populations: Improving outcomes by working together - A report to the
Department of Health and the NHS Future Forum, Kings Fund
http://www.kingsfund.org.uk/publications/integrated-care-patients-and-populations-improving-outcomesworking-together
Integrated Care – Better Care Fund, Local Government Association
http://www.local.gov.uk/web/guest/health-wellbeing-and-adult-social-care//journal_content/56/10180/4096799/ARTICLE
Integrated working for better outcomes, Social Care Institute for Excellence
http://www.scie.org.uk/publications/integratedworking/
Back to joint commissioning
of services
Commissioning
Service User and Public Involvement
Ensuring that the people likely to receive services and their carers are involved in the planning and
commissioning of services. This might be through patient and public Involvement at a population level or with
service users and carers at an individual level.
Back to house
Involvement in planning
Service User Experience
Service user involvement is one of the most
important measures and determinants of quality
in health and social care planning and delivery
Ensuring that their views of service users and
carers are captured so that services commissioned
reflect the needs and preferences of people living
with long term conditions and their carers.
By involving services users and members of the
public commissioning should result in high-quality
services that more adequately reflect user need.
Key Components
• Routine involvement of service users and
carers in service planning
Key components
• Mechanisms are in place to capture the
experiences of people living with long term
conditions and their families and carers
• These experiences inform future commissioning
of services
Commissioning
Involvement in planning
Resources
Transforming Participation in Health and Care, Guidance for Commissioners, NHS England
http://www.england.nhs.uk/2013/09/25/trans-part/
Invest In Engagement, Picker Institute Europe
http://www.investinengagement.info/
Community commissioning case studies
https://www.gov.uk/government/publications/community-commissioning-case-studies
Patient involvement , National Voices
http://www.nationalvoices.org.uk/patient-involvement
People Powered Health, Nesta
http://www.nesta.org.uk/project/people-powered-health
Involving and consulting carers - a good practice guide, Carers UK
http://www.carersuk.org/professionals/resources/practice-guides/item/428-involving-and-consulting-carers-a-goodpractice-guide
Back to Service and Public User Involvement
Commissioning
Service User Experience
Resources
Patient involvement , National Voices
http://www.nationalvoices.org.uk/patient-involvement
Experience Based Design, NHS IQ
http://www.institute.nhs.uk/quality_and_value/experienced_based_design/the_ebd_approach_(experience_based_desig
n).html
Involving and consulting carers - a good practice guide, Carers UK
http://www.carersuk.org/professionals/resources/practice-guides/item/428-involving-and-consulting-carers-a-goodpractice-guide
Improving Patient Experience, NHS England
http://www.england.nhs.uk/ourwork/pe/
Transforming Patient Experience, NHS Institute
http://www.institute.nhs.uk/patient_experience/guide/the_patient_experience_research.html
Patient Experience, Kings Fund
http://www.kingsfund.org.uk/topics/patient-experience
Back to Service and Public User Involvement
Commissioning
Contracting and Procurement
Developing the levers and incentives to enable professionals to deliver person centred
coordinated care for people living with long term conditions. Managing the process of tendering for the
supply of goods and services and awarding contracts. Agree process by which new service/pathway will
be contracted for
Contracting Models
To ensure contracting models are
the most appropriate for the
service commissioned. To
consider models that can be
commissioned jointly across
health and social care.
Key Components
• Statutory procurement
processes
• Standard contract models
• Joint contracting models
Back to house
Reorientation
Service Specifications
Ongoing evaluation process of
commissioned services ensuring
the services provided continue to
meet the needs of changing
populations. Where services are no
longer evaluated as effective this
may involve decommissioning
services and commissioning new
services that better meet the needs
of the population.
Key Components
• Regular evaluation of existing
services
• Processes for decommissioning
services that maintain continuity
and minimise disruption
Documentation which sets out
the necessary requirements of a
commissioned service. These
documents are key to the
contracting process as they not
only describe what form the
service should take but also how
success will be measured and
how performance management
will take place.
Key Components
• Service specifications
• The use of service
specifications to develop
meaningful performance and
quality indicators
Commissioning
Contracting Models
Resources
2014/15 Standard Contract, NHS England
http://www.england.nhs.uk/nhs-standard-contract/
The NHS Standard Contract: a guide for clinical commissioners, NHS England
http://www.england.nhs.uk/wp-content/uploads/2013/02/contract-guide-clinical.pdf
Making savings from contract management, Local Government Association
http://www.local.gov.uk/documents/10180/11417/Making_savings_through_contract_management.pdf/e
56aeb46-7d56-4327-b8ff-8824d136aff7
Back to contracting and
procurement
Commissioning
Reorientation
Resources
Guidance for commissioners on ensuring the continuity of health care services, Monitor
http://www.monitor.gov.uk/node/2462
P3M Resource Centre, Delivering the benefits of change, NHS Connecting for Health
http://www.connectingforhealth.nhs.uk/systemsandservices/icd/informspec/p3m/resource
Back to contracting and
procurement
Commissioning
Service Specifications
Resources
Commissioning toolkit for respiratory services, Department of Health
https://www.gov.uk/government/publications/commissioning-toolkit-for-respiratory-services
Support for Commissioning Dementia Care, NICE
http://publications.nice.org.uk/support-for-commissioning-dementia-care-cmg48
Back to contracting and
procurement
Commissioning
Care Planning
Care planning aims to make best use of health care and local authority services through capturing
the needs and preferences of people living with long term conditions and their carers and ensuring
this information is fed into commissioning processes.
In order for this to happen commissioners for long term conditions services need to consider how
services can be configured to best support the collaborative care planning process.
Back to house
Commissioning to
support care planning
Care planning to support
commissioning
Personal Budgets
Commissioners for long term
conditions services need to
consider how services can be
configured to best support the
collaborative care planning
process.
Ensuring that outputs from the
care planning process are fed
into the commissioning process.
Personal budgets are essentially
a tool for commissioning
services at the level of the
individual. Personal health
budgets are money in lieu of
NHS or social care funded
services which is spent as
detailed in an agreed care plan.
Key Components
• Commissioning supporting
care planning appointment
structures in primary care
• Directory of Services
• Commissioning to support the
information needs of the care
planning process
Key Components
• Recording gaps between
individual requirements and
services commissioned
• Commissioning mechanisms
to capture and transfer care
planning information
• Directory of services
• Using care planning
information to routinely inform
the commissioning process.
Commissioning
Key Components
• Providing people living with
long term conditions with the
option of a personal health or
social care budget
• Directory of Services
Commissioning to Support Care Planning
Resources
How information supports personalised care planning and self care, Department of Health
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/215952/dh_124054.pdf
At a glance 45: Social care and clinical commissioning for people with long-term conditions, SCIE
http://www.scie.org.uk/publications/ataglance/ataglance45.asp
Delivering better services for people with long-term conditions, Building the house of care . Kings Fund
http://www.kingsfund.org.uk/publications/delivering-better-services-people-long-term-conditions
What is a directory of services? Connecting for Health
http://www.connectingforhealth.nhs.uk/systemsandservices/pathways/about/dos
Back to care planning
Commissioning
Care Planning to Support Commissioning
Resources
Long Term Conditions (LTC) Electronic Templates Supporting Personalised Care Planning, NHS
Networks
http://www.networks.nhs.uk/nhs-networks/long-term-conditions-ltc-electronictemplates/show_all_similar_networks
Care Planning, Diabetes UK
http://www.diabetes.org.uk/Documents/nhs-diabetes/care-planning/knowledge-information-repositorycare-planning-diabetes-executive-summary.pdf
What is a directory of services? Connecting for Health
http://www.connectingforhealth.nhs.uk/systemsandservices/pathways/about/dos
Back to care planning
Commissioning
Personal Budgets
Resources
Personal health budgets, NHS England
http://www.personalhealthbudgets.england.nhs.uk
Building on a people’s movement for change, People Hub
www.peoplehub.org.uk
Personal Health Budgets Evaluation
https://phbe.org.uk/
Back to care planning
Commissioning
Tools and Levers
The use of tools and levers to allow for effective commissioning processes to achieve the best outcomes
for the health and social care economy. This can include the use of different tariff models to fund health and
social care support to those with complex needs and commissioning of direct and local enhanced services.
Back to house
Enhanced Services
Tariff and Funding Models
Enhanced services are those which are commissioned
outside of the core primary care contract. They are
commissioned where additional need is identified.
Enhanced services can be developed locally and
nationally to support people living wit h long term
conditions.
Whole population tariff models are not always the
most effective methods for funding care for people
living with complex long term conditions. Alternative
tariff or funding models can be considered based on
the health and social care needs of and individual
rather than based on disease. These models
consider an annual risk adjusted capitation budget
which is based on these levels of need.
Key Components
• Evaluation current services and identifying gaps in
need that could be met through the commissioning
of an enhanced service
• Direct enhanced services (national level)
• Local enhanced services (local level)
Key Components
• Local changes to tariff to support people with
complex needs
• Risk stratification and identification of those with
complex care needs
• Year of Care Funding Model
Commissioning
Enhanced Services
Resources
Enhanced Services Commissioning Factsheet, NHS England
http://www.england.nhs.uk/wp-content/uploads/2012/03/fact-enhanced-serv.pdf
Enhanced Services, NHS Employers
http://www.nhsemployers.org/PayAndContracts/GeneralMedicalServicesContract/DirectedEnhancedSer
vices/Pages/EnhancedServices.aspx
Back to tools and levers
Commissioning
Tariff and Funding Models
Resources
Year of Care, NHS Improving Quality
http://www.nhsiq.nhs.uk/improvement-programmes/long-term-conditions-and-integrated-care/year-ofcare.aspx
Confirmation of the 2014/15 National Tariff, NHS England
http://www.england.nhs.uk/resources/pay-syst/national-tariff/
Back to tools and levers
Commissioning
The House of Care – Build your own house
What elements need to be in place for YOUR local population?
Organisational and clinical processes
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Engaged, informed individuals & carers
Health & care professionals committed to
partnership working
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Commissioning
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Back to house