1. Self Management Strategy & Personal Health Plans
Dr Gerry McCabe
GP & E&N Herts CCG Diabetes Lead

2. Self Management in LTCs
Five Year Forward View
Public Health Strategy in Hertfordshire
Personal Health Planning

3. Self Management in LTCs
Five Year Forward View
Public Health Strategy in Hertfordshire
Personal Health Planning

4. Five Year Forward View (Oct 2014)
Emphasis on prevention and self management
LTCs are a central task of the NHS
People with LTCs spend < 1% of their time with Health Care Professionals
They otherwise self manage
Empower patients:
Improve access to better information
Support people to manage their own health

5. Self Management in LTCs
Five Year Forward View
Public Health Strategy in Hertfordshire
Personal Health Planning

6. Public Health Strategy in Hertfordshire
Self Management Steering Group - 4 Areas
Embed skills to support self management in the workforce & among patients & carers
Develop the role of Community Pharmacy
Support self management outside the NHS (social care and voluntary sector)
Embed risk stratification into self management pathways

7. Public Health Strategy in Hertfordshire
Embed skills to support self management in the workforce & among patients & carers
Funding bid for pilot schemes in E&N Herts and Herts Valleys CCGs
Use psychology expertise
Change the way that health professionals work
Change the way that patients respond to their LTCs

8. Public Health Strategy in Hertfordshire
Embed skills to support self management in the workforce & among patients & carers
Do Something Different
Behaviour change pilot programme for Type 2 DM
/ text message over a 6 week period to support change in established behaviours

9. Self Management in LTCs
Five Year Forward View
Public Health Strategy in Hertfordshire
Personal Health Planning

10. Personal Health Planning Coalition for Collaborative Care 2014
Personalised care and support planning encourages care professionals and people with LTCs to work together to clarify and understand what is important to that individual.
They agree goals, identify support needs,
develop and implement action plans, and monitor progress. This is a planned and continuous process, not a one-off event.

11. VISION
To develop an integrated care plan, used by all providers called ‘My Personal Health Plan’, to ensure that people are involved in managing their condition, receive the care they need to live and die well, and that both they and their carers feel better supported to maintain a good quality of life.

12. Why?

14. Why?
Patients with multiple LTCs are on the rise and we need a more holistic approach to meet their needs
Patients with multi-morbidity end up with many care plans that do not work for them or their clinicians
Variation in delivery of care plans across the CCG
Not person-centred-more disease specific
Evidence suggests it leads to more appropriate use of resources,people more engaged and can self-manage more effectively and adopt a more healthy lifestyle.
Need better integrated approach with whole system buy-in so all health and social care professionals are involved.

15. BENEFITS TO PEOPLE WITH LTCs
Involvement in the decision making process
Better understanding of their condition
Develop ability/increase in confidence to self manage
Provide consistency and continuity of care
Information and sign posting to local services
Opportunity to have a central role in service planning, and agreeing what local care should look like
Involving carers more in regards to identifying and supporting their health and care needs

16. BENEFITS TO CLINICIANS
More satisfying consultations
See better outcomes for people with LTCs
New skill set if it is to be truly integrated.
A lever to drive quality
Less inappropriate use of medications
To test services commissioned that people with LTCs will use.

17. BENEFITS TO COMMISSIONERS
Greater value for money by improving health outcomes and reduce waste
Positive impact on patient experience such as prevent unplanned care.
Provides information needed to commission services that people want and clinicians value
Fits very well with integration agenda and will add value to HomeFirst Plus
Provides sustainable, long term approach to reducing the burden of LTCs on local resources

18. My Personal Health Plan - a work in progress...
About Me
Medical Information
My Preferences
My health action plan
What to do if I become poorly
Additional information and ownership
Contacts and useful information
My notes

19. Self Management Strategy & Personal Health Plans
Five Year Forward View
Public Health Strategy in Hertfordshire
Personal Health Planning
Thank you - any questions?