1. Diabetes & Endocrinology
Collaborative Patient Care: How might it look in the world of Diabetes?
Dr Rohana Wright
Consultant Physician
Diabetes & Endocrinology
St John’s Hospital

2. Objectives
The case for change
House of Care
Care planning in practice

3. A year in the life of a person with diabetes
3 out of 8757 hours
or 0.03%

4. had at least one check up in the last 12 months
Poor quality of care and ineffective use of resources
discussed ideas about best way to manage their diabetes
agreed a plan to manage their diabetes over next 12 months
discussed their goals in caring for their diabetes

5. LTCs are the most common cause of death and disability
LTCs are the most common cause of death and disability. People with LTCs account for:
70% of the money spent on health and social care
55% of GP appointments
68% of hospital outpatients
77% of inpatient episodes
Over half of the overall cost of looking after older people in residential homes

6. The ‘House of Care’ Approach
What is it all about?
Person-centredness
Informed patients
Constructive conversations with active participants
Improved outcomes:
Clinical
Patient and Staff satisfaction
the system needs to support individuals to develop the knowledge, skills and confidence to manage their own care
Using ‘care planning’ to address these issues

7. The evidence for a new approach: Year of Care

8. Tower Hamlets
92% of registered population (Type 2 diabetes) taking part in care planning
Patient perceived ‘involvement in care’ rose from 52-82%
72% received all 9 processes in National Diabetes Audit: Best in England (Average 49%)

9. Kirklees: Improvement programme : saved £225K
Cost per patient
practice level
pre YOC: £21
post YOC: £21
Kirklees: Improvement programme : saved £225K
Tower Hamlets: Emergency admissions reduced by 15%.. saved £700K

10. House of Care

13. Enabling good conversations
Philosophical shift for some
Skills and experience
Learning from each other

14. Enabling good conversations
Supported self-management/self-directed support:
Sharing information
Building confidence
Problem solving skills
Peer and group support

15. Enabling good conversations
Making best use of resources across statutory and third sectors and in community
Responding to need by allocating resources differently
Is it working?

17. Care planning – what does this mean?
This is the part where we usually do some role play…

18. Scenario 1
A bank contacts a customer and asks them to attend a meeting with the bank manager
The customer attends…with some trepidation
The manager announces the degree of debt/trouble that the customer is in and asks how they are going to fix the issue?
The customer is scared and goes home feeling very confused/troubled/not clear at all where to go from here……

19. Scenario 2
The bank sends a customer some information about some spending/debt issues seen in their accounts, and suggests it might be good to meet up to discuss
The customer looks through the information, discusses with family, can see where things may have gone wrong, and where some of the over spending can be curbed and finances recouped
Bank manager and customer meet up to discuss – both fully understanding the issues in advance, and the customer has a plan of attack to set things moving in the right direction..

24. Care and support planning (Dr Sue Roberts)
Care and support planning is about enabling better conversations between people living with long term conditions (LTCs) and health care practitioners that are focussed on what matters to the individual so that support and services can be tailored for each person.
It is a meeting between those with technical expertise and those with lived experience in which the person is supported to identify their priorities and goals for living their life and the actions that they and/ or the service can take to help them achieve these.

25. “But we do all this already...”
2 core philosophies:
They are in charge of their own lives and self-management of their diabetes, and are the primary decision makers and risk takers, about the actions they take in relation to their diabetes management.
People are much more likely to undertake action in relation to the decisions they make themselves than decisions that are made for them.

26. Feedback
“ Before, things seemed to get forced on you… whereas this way I prefer to discuss it myself… there’s more of a choice now, it’s my choice rather than someone else’s choice, that’s why I like it.”
Person with diabetes, reporting on their experience of the YOC approach to care planning
“ If I were a patient I would want to have a care planning system in place. I think it respects people more as individuals. It gives people more rights.”
Practice nurse, involved in care planning

27. “ Care planning has made me look at patients differently
“ Care planning has made me look at patients differently. I focus less on the disease and take a more holistic perspective.”
Practice nurse
“ Each time I get a greater understanding of my condition and understand more about how I can go about maintaining and improving it.”
Person with diabetes

28. Any thoughts/questions?