We wanted to ensure that people with heart and circulatory disease received a collaborative care and support planning consultation. One that focused on what was important to them and supported them to learn more about their condition and access community-based services and activities to help them achieve their goals.
- introduce care and support planning into routine care
- change local care pathways for heart and circulatory diseases, driven by care and support planning
- encourage practices to build relationships with local community and voluntary services to provide a wider range of activities that support people to self-manage their condition(s)
The ambition was that in the long term people with heart and circulatory conditions would be supported more effectively in the community, and that care and support planning would become the routine experience of care.
Throughout the programme we followed the journey of staff and stakeholders at each site as they introduced care and support planning and captured lessons learnt. Initially, the programme was intended to run for two years but was extended to allow more time for sites to make and embed the necessary changes for success.
More detailed information about the establishment and operation of the programme is included in the ICF evaluation report [PDF].
The final evaluation in March 2018 included a mixture of self assessment by sites and participant interviews and questionnaires. These included people with LTCs, general practitioners (GPs), nurses, pharmacists, healthcare assistants (HCAs), project managers, practice managers, receptionists, clinical commissioners and other service providers.
Through its evaluation we hope to highlight the benefits and challenges of using the House of Care framework to share learning with other health communities considering adopting the care and support planning approach.
Our pilot sites
The five pilot sites in the House of Care programme were selected because they serve populations with some of the highest levels of deprivation and deaths from heart and circulatory conditions in the UK.
NHS Hardwick CCG
Covers 100,000 people living in some of the most disadvantaged areas of Derbyshire. The area has higher rates of heart attack, heart failure admissions and stroke admissions than the East Midlands average.
NHS Newcastle Gateshead CCG*
Serves a population of 525,000 with high levels of deprivation, unemployment and a growing elderly population. Death rates from circulatory diseases are much higher than the England average.
NHS Greater Glasgow and Clyde
Serves a population of 1.2 million, with around 240 GP practices. Around 35% of under-75s in this area live in some of the most deprived areas of the UK. The population is more elderly than the Scottish average and has poorer life expectancy and greater mortality rates for coronary heart disease.
Serves a growing and aging population of 850,000, with the number of over-75s expected to increase by 22% between 2013 and 2020. Obesity, poor diet, limited physical activity and high smoking rates are major challenges.
Serves around 170,000 people in the urban area of Dundee. The population is older and has shorter life expectancy than the Scotland average.
Scottish Government and the Health and Social Care Alliance Scotland have funded and supported two further Scottish House of Care sites.
*Gateshead and Newcastle CCGs merged in 2015. The evaluation focuses only on work in Gateshead as this was a single site at the time of funding.
Source: Data was provided by sites at a programme launch event in March 2015 and reflects the picture on the ground when funding commenced in 2015.
Putting people at the heart of their care
Our publication describes the aims, outcomes, evidence and lessons learnt for future implementation from the BHF House of Care programme.