The overall aim of the Year of Care programme was to systematically test if care planning could be implemented as ‘normal care’ across different and diverse health communities. The approach aimed to ensure that people with diabetes had active involvement in deciding, agreeing and owning how their condition is managed, including an agreed plan for self-management.
Three pilot sites of differing histories in standards of care were chosen, with each undertaking a complex range of activities to improve self-care. Central to this was training and support for practice teams, as well as using a healthcare assistant to gather and send information to patients ahead of consultations. At the end of the pilot, 76 per cent of people on practice registers with Type 2 diabetes had attended at least one care planning consultation.
NHS Diabetes, Diabetes UK, the Department of Health and The Health Foundation jointly funded the Year of Care programme.
Care planning aims to puts people with diabetes firmly in the driving seat of their care and supports them to self-manage their condition. In diabetes it aimed to transforms the tick box annual review into a constructive and meaningful dialogue between the healthcare professional and the person with diabetes by enhancing the routine biomedical surveillance and ‘QOF review’ with a collaborative consultation, based on shared decision making and self-management support, via care planning.
In addition by working across an organisation the Year of Care Partnership aimed to then ensure that the local services people needed to support the actions they want to take to improve their wellbeing and health outcomes were made available through commissioning.
Rationale for the programme
The Healthcare Commission Survey of 2007 identified that while routine diabetes care resulted in a high attainment of ‘checks’ being performed, patient surveys indicated that only about half of these consultations involved people with diabetes discussing their ideas, being involved in identifying goals and developing a self-care action plan. Within routine NHS diabetes care there was a focus on ‘doing to’ rather than ‘working with’ patients.
This was despite evidence that good outcomes can best be achieved when structured and organised healthcare systems work in collaboration with empowered and engaged patients (Wagner Chronic Care model). The reality is that in a condition like diabetes, most of the time people who live with the condition ultimately make decisions about the day-to-day management of their own condition.
In addition healthcare policy was focusing on the need to involve people with long-term conditions in decision-making, especially around self-care. The NHS Plan (2000) emphasised that: ‘The health and social care system must be shaped around the needs of the patient, not the other way round. Step by step over the next ten years the NHS must be redesigned to be patient centred – to offer a personalised service.’
In diabetes this was outlined within Standard 3 of the Diabetes NSF, which encouraged a partnership approach to decision making via the process of agreeing a care plan.
The overall aim of the Year of Care programme was to determine if it was possible to embed care planning as the normal way to deliver routine diabetes care across whole health communities.
It had two key objectives:
- To enhance the routine biomedical surveillance and ‘QOF review’ with a collaborative care planning consultation, based on shared decision making and self-management support within general diabetes care
- To ensure that there is a choice of local services are available to support self-care.
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