Introduction
Sharing Solutions for a Shared Challenge
The increasing number of people living with long term conditions presents a major challenge for health, social care, community and voluntary sector partners. Better awareness of their long term conditions helps people understand their symptoms and experiences and improves their long term health and wellbeing. The role of the care professional is to encourage self confidence and the capacity for self management and to support people to have more control of their conditions and their lives.
The national Long Term Conditions Collaborative ( LTCC) improvement programme, the Scottish Government's Long Term Conditions Unit ( LTCU), the voluntary sector represented by the Long Term Conditions Alliance Scotland ( LTCAS) and others are working together to promote self management approaches across Scotland.
A Self Management Fund, launched in March 2009, will be a catalyst for testing, implementing and learning about self management. It will do so through a combination of grant aid and support for networking and learning. The fund is specifically targeted at voluntary and community health organisations and groups, for projects that support sustainable and innovative approaches to self management. These projects will be complemented by other work that will help us to change the culture within NHSScotland to one which is mutual and informed by service users. More information on LTCAS and on the Self Management Fund can be found at www.ltcas.org.uk, or by calling their offices on 0141 404 0231.
The Long Term Conditions Collaborative's focus is to support shared learning and to provide tools, techniques and a range of practical supports to enable partnerships to deliver timely, safe, effective, efficient and equitable services that achieve better outcomes and an enhanced experience of care. Approaches include Plan Do Study Act ( PDSA) cycles, lean-thinking, targeting steps and activities that don't add value and addressing capacity and flow to improve pathways, reduce delays and to increase reliability and productivity across the whole system.
High Impact Changes and Improvement Actions
The Long Term Conditions Collaborative developed a set of clear and tangible improvements that we expect to make a big impact on the way people with long term conditions manage their own care and experience care provided by others.
These High Impact Changes are generic and apply across the long term conditions pathway from diagnosis through self management, living for today, change in condition and transitions of care to palliative and end of life care.
Each High Impact Change has a bundle of Improvement Actions, all of which have to be implemented to successfully deliver the change. These improvement actions are based on changes that have been tried and tested in the UK and beyond. They reflect what people living with a long term condition have said should be done to improve their experience of living with a long term condition.
Supporting Delivery
We have identified examples of improvement actions that will help you to support self management. The list isn't exhaustive, or intended to be a comprehensive evidence base. It reflects the experience in Scotland and builds on examples outlined in Scotland's approach to self management set out in the strategy document Gaun Yersel1, developed by people with long term conditions in partnership with the Long Term Conditions Alliance Scotland ( LTCAS).
We hope that the background information, ideas, examples and contacts in this resource provide you with practical ways to improve care for people living with long term conditions
Defining self management support and the Principles of Self Management
LTCAS defines self management as 'the successful outcome of the person and all appropriate individuals and services working together to support him or her to deal with the very real implications of living the rest of their life with one or more long term condition' .
Support for self management is what services provide to encourage people to take decisions and make choices that improve their health, wellbeing and health-related behaviours. It can be viewed in two ways: as a portfolio of techniques and tools, and as a fundamental transformation of the relationship between the person living with long term conditions and their caregiver into a collaborative partnership.
Support for self management requires a focus on improving health and wellbeing and reducing health inequalities and involves:
- Providing individualised assessments of self management support needs
- Tailoring self management support to an individual's preferences, culture, level of comprehension, skill, educational need and learning style
- Systematic assessment of individual self management goals
- Supporting self management goals follow up (including the way in which confidence in achieving goals is monitored and recorded)
- Developing ways to ensure that people are actively involved in planning their self management support
- A shared and explicit multidisciplinary team understanding of what self management support means and an ability to explain this clearly
- Sharing information on self management needs, goals and plans
- Considering ways in which people living with long term conditions can become involved in the provision of self management support
- Developing systems of referral and monitoring for self management support provided by non NHS services
- Training for generalist and specialist staff across professions and agencies to listen, inform, empower and enable people to self manage
- Attention to the role of unpaid carers
- Easy to access information, educational materials and multi-media interactive programmes
Principles of Self Management
The principles set out in Gaun Yersel propose a more holistic approach, less emphasis on a model of medical interventions and specific outcomes and a shift towards care environments that are both clinical and therapeutic. These principles are a valuable contribution to the discussion about taking forward a mutual NHS in Scotland which affirms people as partners rather than recipients of care. They will help us create a cultural change that balances our emphasis on evidence-based technical interventions with the humanisation of care.
This resource will help you and your team to implement these principles as you make local improvements in care for people with long term conditions by:
Raising awareness of the principles and make them available to staff
Referring to them in appraisals, job descriptions and project proposals
Reflecting on how your Long Term Conditions Action Plan will help make them a reality
Using the principles as a basis for tests of changes that will enable people to manage their condition
Taking steps now to systematically test and spread the ten approaches outlined in this document