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Legacy and next steps for care and support planning

We summarise the legacy of the BHF House of Care programme, lessons learnt and next steps.

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A legacy for sustained care and support planning

We asked sites to tell us if they would sustain the changes they made during the programme. All sites strongly favoured continuing care and support planning and most sites intend to expand it to a wider population of patients with long-term conditions (LTCs) or to neighbouring practices and health economies.

NHS Lothian

  • 1-in-5 Lothian practices received information and training about House of Care

Individual practices are beginning to include additional LTCs. At site level, the Lothian House of Care Collaboration is rolling out wider care and support planning training. Work is ongoing to integrate the care and support planning approach with secondary care (initially in cardiac rehabilitation) and to engage other healthcare professionals such as pharmacists.

NHS Tayside

  • Seven Tayside practices have adopted care and support planning

Seven practices are using a care and support planning approach, a further 14 have received staff training and four of these are planning to introduce the House of Care framework (three for people with heart and circulatory diseases). Most practices felt care and support planning would be sustained in practices where it was already in place.

NHS Greater Glasgow and Clyde

  • Three trainers are now in place to deliver care and support planning training

Care and support planning is live in 14 practices and they have secured a year’s funding to continue the project manager role. Three quality-assured trainers are already in place to support further work. The team is considering whether GP Cluster Leads could play a greater role in driving the spread of care and support planning.

NHS Newcastle Gateshead CCG

  • 100% of practices in Gateshead now use care and support planning

All 32 practices across Gateshead are implementing the House of Care for multiple LTCs. Six Gateshead trainers are in place to deliver quarterly top-up training and bespoke support to practices, and the team is producing a film about care and support planning to share the approach more widely.

NHS Hardwick CCG

  • 1,483 people received a care and support planning review

Eleven out of 18 practices have adopted the House of Care framework and some practices are extending care and support planning to include people with other LTCs. The prevalence of LTCs and a strong local track record of person-centred care made care and support planning a priority for this site and more widely across Derbyshire. 

Lessons learnt

The BHF House of Care programme has contributed to lessons learnt from implementing the care and support planning approach via the exemplar of heart and circulatory conditions and other long-term conditions.

This programme has built upon work by the Year of Care Partnerships to identify critical success factors for implementing the House of Care. The lessons learnt from this programme are as follows.

Clinical leads are important. It was vital for clinicians to articulate the vision for care and support planning to facilitate practice buy-in and for staff to receive tailored training from healthcare professionals they respect and trust.

Involve people with LTCs. Patient reference groups played a significant part in championing this approach. In Gateshead they designed leaflets, engaged with receptionist groups, and developed and promoted the OurGateshead community website, which connects people with follow-up services.

Equip the workforce with ongoing training. In addition to initial Year of Care Partnerships training, short tailored ‘top-up’ training, Learning Sets and Train the Trainer approaches to support practices were highly successful in equipping professionals to have effective collaborative conversations. Practices need time to learn about how to adopt a care and support planning approach in addition to developing systems and tools.

Include the whole team. This helps to establish new processes and culture from the start and reduces the impact of staff changes. It includes practice management and administrative staff, as well as practice nurses, GPs, pharmacists and healthcare assistants.

Allow time for building the roof. Teams said it was essential to ensure infrastructure changes are in place before extending the approach to additional practices or sites. It can take at least six months to put systems in place before care and support planning can start, and two to three years before it is fully embedded.

Project management and practice facilitation are important. This can be combined with training and practice facilitation roles. Project managers at the different sites were trained and became involved in different ways. All project managers responded to emerging needs and encouraged practices to include more LTCs. They have been kept in post to support the spread and adoption of care and support planning.

Flex the framework to meet local needs. While maintaining the core components, some practices tailored these to meet their practice and patient needs. Nurses visited the housebound or included telephone conversations, while others developed a picture format and colour coding system in the results letter to help those with poor health literacy. 

Next steps for adopting care and support planning

We want the legacy of this programme to lead to sustained change in NHS care across the UK. That starts with you.

Healthcare professionals: If you are a front-line healthcare professional, share what you’ve learnt with colleagues and local patient groups. Discuss how this approach could benefit your patients. Speak to your local health board or commissioning group about whether this approach is being trialled in your area and whether your team can get involved. If it isn’t, ask for this to be considered.

Commissioners/planners: As a healthcare commissioner, planner or clinical lead, reach out to colleagues in our Health Services Engagement team (see Contacts and Further Information section) to discuss how this approach could work for your population and what you’d need to get this started. You can also speak to the Year of Care Partnerships about the support they can provide.

Patients: If you’re a patient or a member of a patient group, ask your local general practice whether they would consider adopting care and support planning. Help to spread the word about how this approach can deliver better, person-centred care. Learn more about what this approach means for your care in our Information and Support section

Find out more: Visit our other webpages about the House of Care for more information, and access the Year of Care Partnerships website for a wealth of resources around care and support planning and the House of Care.

You’ll find inspiration, evidence and useful advice for everything from making the case for change to getting started with your own programme or maintaining an ongoing initiative.

Join the debate on social media, including in our LinkedIn Group for healthcare professionals. Learn from the experiences of others and share challenges and successes.

It’s in your hands.

Next: Resources and information

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