This paper describes a co-ordinated service delivery model – the ‘house of care’ – that aims to deliver proactive, holistic and patient-centred care for people with long-term conditions. It incorporates learning from a number of sites in England that are working to achieve these goals, and makes recommendations on how key stakeholders can work together to improve care for people with long-term conditions.
The model differs from others in two important ways: it encompasses all people with long-term conditions (not just those with a single disease or in high-risk groups) and it assumes an active role for patients, with collaborative personalised care planning at its heart.
The house of care metaphor illustrates the whole-system approach needed to improve care, and emphasises the interdependency of each part. Care planning is at the centre; the left wall represents the engaged and informed patient; the right wall represents health professionals committed to partnership working; the roof represents organisational systems and processes; and the foundations represent the local commissioning plan. Key elements are as follows.
People with long-term conditions play an active part in determining their own care and support needs through personalised care planning.
Collaborative relationships between patients and professionals, shared decision-making and self-management support are at the heart of service delivery.
Tackling health inequalities is a central aim, given that people in lower socioeconomic groups are more likely to experience long-term conditions.
Each individual is engaged in a single, holistic care planning process with a single care plan regardless of how many different long-term conditions they have.
Individual needs and choices are aggregated to provide a local commissioning plan.
Self-management support may be provided by community and self-help groups alongside statutory services.
NHS England and the Department of Health should work together to encourage a coherent approach at national and local level to care planning for people with long-term conditions.
NHS England should develop and test funding mechanisms and encourage the development of technology to support planning and information-sharing.
More on long-term conditions
Read Angela Coulter's blog: Supporting people with long-term conditions: what is the house of care?