Northern England Strategic Clinical Networks

Person Centred Health and Shared Decision Making

Living with Long Term Conditions

Almost 70 per cent of the overall health and social care budget is spent on people with long term conditions. We aim to support those who commission and provide services for people with long term conditions to deliver quality improvements in services.

Fundamental to this work is the understanding that long term conditions are different – the acute, biomedical model of healthcare simply does not apply. We need to work in partnership with patients, promoting and supporting their role in making decisions about their health and wellbeing. We need to move towards a more holistic, personalised, systematic approach, providing more proactive access to the services people want and need.

Priorities:

  • Establish a shared vision for people with long term conditions, providing support for self-care to improve quality of life and outcomes.
  • Develop quality standards and metrics.
  • Implement care planning – every person who has a long term condition is offered a planned, proactive care planning appointment.
  • Reduce avoidable and unnecessary emergency and unplanned care, through effective case management and improved services for people with complex needs.
  • Support clinical engagement and leadership, sharing and implementing best practice, involving patient and carers and working with appropriate networks.

Supported self-management

Self-management is an important aspect of person-centred health.  The Health Foundation identified the main components of supported self-management as:

  • People with long-term health conditions working collaboratively with health professionals, to determine realistic goals and how to achieve them;
  • People being able to live a full and meaningful life, through being supported with the knowledge to understand their condition and tools to manage symptoms and limitations with confidence;
  • The ability to access the services they need in a timely manner, to help with managing their health and wellbeing on a day-to-day basis.

Supported self-management applies to a broad range of conditions, and is a theme that cuts across all of our network areas.  This workstream aims to increase understanding of what supported self-management is and how organisations can embed it into their delivery.

There are a number of web-based resources relating to supported self-management, which can be accessed below.  This page also provides information on ongoing projects in our network area with a supported self-management focus.  Please get in touch if there are any other projects that aren’t included that you think are relevant.

Useful resources

Health Foundation: http://www.health.org.uk/

Pain toolkit: http://www.paintoolkit.org/

Self-management Network Scotland: http://smns.alliance-scotland.org.uk/

NHS England Five Year Forward View: https://www.england.nhs.uk/ourwork/futurenhs/

Realising the Value (NESTA): http://www.nesta.org.uk/project/realising-value

Local projects

South Tyneside Pioneer Project – A Better U: http://www.wellbeinginfo.org/a-better-u

Northern England Neurological Conditions Network supported self-management workbook

Shared decision making

Involving People in their Care is a cross-cutting theme for the Northern England Strategic Clinical Networks. The House of Care framework includes ‘engaged, informed patients and carers’ as essential in delivering person-centred, coordinated care.

‘No decision about me, without me’ needs shared working so decisions are made by patients and practitioners in partnership.

Shared Decision Making (SDM) is a process in which patients, when they reach a decision crossroads in their health care, can review all the treatment options available to them and participate actively with their healthcare professional in making that decision. NHS England

We work with the NE Shared Decision Making Community of Interest (CoI) which was set up to build support for shared decision making and to provide a stimulus for widening interest in, and implementation of, SDM across North East England. It provides a forum to share experiences, promote exemplar best practice, gain knowledge and skills within a safe environment, increase organisational and clinical engagement, support clinical implementation, nurture clinical organisational and patient champions, discuss, debate and question.

To join the CoI, please contact:

Susan Hrisos, Senior Research Associate. Tel:  0191 208 6774

Email: Susan Hrisos

Melissa Girling, Research Associate. Tel:  0191 208 5874

Email:  Melissa Girling

Further links

NHS England’s approach to shared decision-making

Meetings