How to relieve pressure on the NHS

How to relieve pressure on the NHS New model, the house of care, places the patient at the heart of the delivery system and encourages personalised care planning.

As the NHS faces the challenge of improving care for the 15 million people with long-term conditions, one hope for improving health outcomes while balancing the books is to shift from a reactive healthcare system that treats people when they become ill, to a proactive one that co-ordinates care and supports people to stay well. The Wanless report said as much in 2002, but progress towards this goal has been painfully slow.

The need for this shift is acute for people with long-term conditions who use at least 50% of all GP appointments, 64% of hospital outpatient appointments and 70% of inpatient bed days, accounting for £7 out of £10 of healthcare expenditure. The growing number of people with more than one long-term condition – projected to rise from 1.9 million in 2008 to 2.9 million in 2018 – poses a particular problem. The Department of Health has calculated that this could add an additional £5bn to NHS costs unless better ways can be found to organise services.

Most agree that what's needed is a concerted effort to promote integrated person-centred care for these people. But how can that be achieved? We now have a model – the house of care – that shows how it could be done.

The house of care is both a metaphor for a proactive co-ordinated system of care and an implementation checklist. Devised to help primary care staff and commissioners reorganise local services, it explicitly places the patient at the heart of the delivery system. The house has a foundation, two walls and a roof. The left wall represents the engaged and informed patient; the right wall is health professionals committed to partnership working; the roof is the practice infrastructure and organisational systems that must be adapted to support personalised care planning; and the foundation is the responsive local commissioning body and community stakeholders that enable this change to take place.

Personalised care planning is at the centre of the house, the fulcrum of a co-ordinated delivery system. People with long-term conditions are encouraged to play an active part in determining their own care and support needs. In pre-arranged appointments they engage in a collaborative care planning process, identifying priorities, discussing care and support options, agreeing goals that the patient can achieve for themselves, and co-producing a single holistic care plan with a shared record that is used to review progress on a regular basis.

The model builds on the experience of 3,000 primary care practitioners in 26 communities who have begun to implement it via the Year of Care programme and similar initiatives. Instead of focusing on a standard set of disease management processes, the aim is to ensure that patients' values and concerns shape the professionals' response. It requires clinicians to rethink the way they work, recognising that the knowledge and experience the patient brings to the care planning process is as important as the clinical information in the medical record.

This demands new skills in risk communication, shared decision making and self-management support that are not routinely taught in professional training programmes. And professionals must be willing to listen to patients and adapt clinical protocols when necessary.

The model has major implications for commissioners, too. Individual needs and choices identified during the care planning process can be aggregated to provide a local commissioning plan. This may need to go beyond the type of services normally provided by the NHS. Community and self-help groups can often provide the type of support to people with long-term conditions that statutory services tend to ignore, for example, cookery classes to help those struggling to eat a healthy diet, gardening projects to encourage physical exercise, volunteer befriending schemes to combat social isolation and loneliness, advice centres and peer-led self-help groups. Mapping local community groups and services into electronic health directories to facilitate signposting and referral is an important component of the house of care, but it depends on local commissioners' willingness to support these non-traditional services.

Aggregating the support needs identified by individuals into a commission plan for a locality requires robust electronic records and systems for data-sharing. Yet many local projects are hampered by inflexible systems that allow no space for recording patients' goals. And of course people's care needs may span multiple organisations and service boundaries, so professional silos and fragmented budgetary responsibility add even greater complexity. Success depends on building effective local partnerships between NHS, social care, public health and community organisations, with appropriate support from NHS England and other national bodies. Clinical commissioning groups will need to be ambitious if they are to change traditional ways of working and realise the benefits in terms of better outcomes and greater value for money. Guardian Professional.