The British Heart Foundation (BHF) is supporting and providing grant funding to three health and social care organisations across five pilot sites in the UK to improve services for people with Long Term Conditions (LTCs) focussing on those who live with, or are at risk of developing cardiovascular disease (CVD). The project is focusing on using a care and support planning approach as described by Year of Care. Pilot communities of practice consisting of a population size greater than 50,000 across 8-10 GP Practices and are big enough to affect change across the health and social care system.
The communities of practice are:
• Newcastle Gateshead CCG
• Hardwick CCG
• Health and Social Care Alliance Scotland (three sites in NHS Tayside, NHS Lothian, NHS Glasgow and Clyde)
The programme aims to:
1. introduce collaborative care and support planning as routine care, mainly within primary care, and develop a holistic review in place of the current tick box surveillance activities encouraged by QOF.
2. redesign local pathways for cardiovascular disease services, driven by care and support planning.
3. develop engagement with a wider range of activities to support self-management within the community, including the third sector. The programme seeks to establish better conversations which support self-management and enable people to be more in control of their lives.
The project scope and target groups were specifically selected to address the needs of populations with health inequalities, high deprivation and high prevalence of CVD.
CVD is a complex group of diseases and conditions, affecting nearly seven million people in the UK. The condition is often long-term, comes with co-morbidities, and results in complex pathways of care – there is clear scope for care and support planning to be of benefit (Nichols et al 2012). Despite this, care and support planning has been tested in a fairly limited way with this patient group – the focus has been on other LTCs, particularly diabetes). However, there are affinities between the conditions which suggest that the House of Care will also work well with CVD, which increasingly occurs alongside other LTCs. Consultations should be framed around patient priorities and begin with the sharing of results, discussing risks and working with people how best to achieve the outcomes important to them.
BHF is providing grant funding, project management, support to self-evaluate and training support via the Year of Care Partnership to projects sites. The programme aims to embed the House of Care – a whole-system approach to establishing, implementing and sustaining a new model of care based around collaborative care and support planning (CSP) in the sites in England and Scotland. Ultimately, the programme aims to ensure that individuals with cardiovascular disease engage in a collaborative care and support planning consultation, focussed on what is important to them, where they are supported to access a wide variety of community and voluntary sector activities and services.