Year of Care: Effective commissioning for diabetes services

The Year of Care is a pilot initiative being delivered in partnership between the Department of Health (DH), Diabetes UK, NHS Diabetes and The Health Foundation. At its heart are two elements: collaborative care planning, which is now widely recognised as being an essential part of routine care, and effective commissioning.

The Year of Care aims to make every consultation between clinicians and people with long-term conditions truly collaborative (through care planning), and then ensure that the local services people need to support this are identified and available (through commissioning). Three pilot sites are testing this approach in England – Calderdale and Kirklees, North of Tyne and Tower Hamlets – and since the introduction of the national target that everyone with a long-term condition should be offered a care plan by 2010, a host of other areas are learning lessons from the pilot sites (DH, 2008a)

Although the programme predated the publication of World Class Commissioning: Competencies (DH, 2007) and Lord Darzi’s report, High Quality Care for All: NHS Next Stage Review Final Report (DH, 2008a), it has the same key elements and ideals at its heart.

The Year of Care aims to engender a genuine cultural shift in the way that care for people with long-term conditions is provided, and to change the relationship between both the person with diabetes and their healthcare professionals, and the relationship between this partnership and the service.

Care planning
Central to improving these relationships is care planning. The value of engaging people with diabetes, or with any long-term condition, in their health and self-care is supported by a wealth of evidence and is underpinned by the National Service Framework (NSF) for diabetes (DH, 2001). Care planning is the vehicle through which this can be achieved, and has been described as “looking with, rather than at someone with diabetes” in the National Diabetes Support Team’s (now NHS Diabetes) guide to implementing effective care planning (2008a). One of the guide’s key messages is that it is “care planning” – the verb – that is important rather than – the noun – the physical care plan. While having a written care plan is important for many people, it is the process of collaborative care and joint working, rather than the end product, which is helpful. Care planning can therefore be seen as an end in itself, although within the Year of Care it is also a means to an end.

Each individual’s collaborative care planning consultation identifies what support they need to meet their personal goals and self-care effectively, from which healthcare professionals and the person with diabetes can decide which local services can help achieve this. This selection of choices from a “menu” of services can be described as micro-level commissioning. At a population level, these choices can be collated and used by commissioners to ensure that the specific support and services required are being provided and are available to use, which can be described as macro-level commissioning. This is illustrated in the diagram below that forms the basis of the Year of Care model (Figure 1).

By creating an environment in which people with diabetes and healthcare professionals are seen as equals, and the person’s “story” is given the same level of importance as clinical expertise, an action plan can be agreed to meet people’s goals for their life and their condition. These need not be service actions, but could relate to changes that the individual chooses to make in their lifestyle that are personalised and relevant to their specific situation. Building on the individual’s priorities in their life at that time to identify actions to help them achieve their goals leads to much more satisfying consultations for both people with diabetes and healthcare professionals.

Commissioning
Commissioners also benefit under the Year of Care as they are able to tap into the one-to-one relationship that healthcare professionals have with people with long-term conditions to get a better understanding of the aspirations of their communities. Furthermore, for the first time the Year of Care allows them to use genuine local patient data to inform the development of local services.

By way of illustration, commissioners may currently know that 100 people locally have a BMI above 30 kg/m², and that over the past year, 12 of those people had achieved a 5% weight loss. From this paucity of data PCTs and practice-based commissioning (PBC) consortia are expected to draw conclusions about which services to commission to help people achieve positive health outcomes.

With the Year of Care approach, PCTs and PBC groups have considerably more information at their disposal to help ensure that they procure the most appropriate local services. For example, by recording goals in care-planning consultations they may discover that actually only half of those 100 people with a BMI over 30 kg/m² wanted to lose weight in the first place. Of these 50, they may learn that only 30 of them agreed a follow-up intervention or action to help them achieve this goal, and they may then learn what interventions or actions these were, as well as the eventual outcomes they led to.

Moreover, people with diabetes and healthcare professionals are able to flag up gaps in, and barriers to, access of local services. To continue the example above, commissioners will be able to learn why only 30 of the 50 people wishing to lose weight undertook an action to address this and what the remaining 20 would have wanted to help them achieve their goal. These barriers or gaps need not necessarily be about the services per se – although this is a useful mechanism for highlighting that, for example, people would like a healthy cooking club in their village. It can also be used to highlight problems with local transport links or a lack of affordable child care facilities. This is explained in more detail in Getting to Grips with the Year of Care: A Practical Guide (National Diabetes Support Team, 2008b).

Developing IT systems
Capturing clinical goals in such a way as to usefully inform the commissioning process requires sophisticated IT systems. To this end the Year of Care has been working in partnership with Dr Richard Pope and NHS Yorkshire and the Humber to develop primary care IT templates that can record individuals’ goals in their own words in a way that can be coded and interpreted by commissioners. These templates have been piloted in TPP SystmOne and their effectiveness proven, and a definitive specification has now been produced to aid the development process in other IT systems. This was shared at a national meeting of all the manufacturers of primary care systems in August.

The “Windmill” model
Commissioners’ involvement in the Year of Care has been a two-way process. The pilot sites initially identified four specific commissioning tasks that were required to support the Year of Care approach:

1. Commissioning care planning.
2. Developing the menu of local options.
3. Linking micro- to macro-level commissioning.
4. Service user (patient and public) involvement.

As work progressed, the sites found that these four elements naturally linked in to their wider organisational work on commissioning. A model was created – the commissioning “Windmill” – that the sites use to break the complex area of commissioning down into more manageable tasks (Figure 2).

Based on the principles established in World Class Commissioning: Competencies (DH, 2007), and with people with diabetes at its core, each sail on the windmill represents an area of relevant commissioning activity. The inner part of each sail identifies one of the specific work areas of the Year of Care, without which it would not be possible to deliver the benefits, and the outer part of the sail links this back to the wider activity the sites found they were drawn into, both to enhance the benefits and to ensure sustainability and local spread. The sites also found that using the model in this way was extremely valuable for the recent World Class Commissioning assurance round, providing them with a systematic way in which to demonstrate achievement of the eleven competencies (see DH [2008b] for more information).

Sheila Dilks, Executive Director for Primary Care and Professions from the pilot in Calderdale and Kirklees, said “If you think of World Class Commissioning as the framework for developing local models of care, we’ve found that the Year of Care is the perfect vehicle in which to do it. Interventions like this that are driven by primary care are uncommon, and so this has been a really unique opportunity to harness all the expertise and enthusiasm in GP practices and use it to shape local care.

By putting people with long-term conditions at the centre of their care we are in a much better position to support them to achieve their goals, rather than just ticking boxes or even lecturing them about what they should and should not be doing. The Year of Care has triggered a real cultural shift in which collaboration and partnership working is allowing us to maximise the full potential of the relationships people have with their clinicians.”

Conclusion
The response to the Year of Care has been overwhelmingly positive, benefiting healthcare professionals, commissioners and people with diabetes alike. It provides a lever for healthcare professionals to agree more time with their patients, and allows them to provide the information needed to commission services that people want and clinicians value. A collaborative approach to care is essential for achieving this.