Putting it into practice: optimising systems and processes

Changes which enable people to self-manage can be made at every level, from what is commissioned to IT systems and individual interactions with people with long-term health conditions. Examples include the following:

  • Developing care pathways to create better links and referrals between statutory, voluntary and community sectors. For example, the ALISS project is a co-produced library that can be added to by anyone and is designed to make information about local sources of support easier to access.
  • Providing services in different ways. This could be through support groups, emails, text messages, and telehealth, to provide ongoing support between face-to-face appointments. For example, the telehealth service in Newham combines different levels of support for people with a range of conditions via virtual education and symptom monitoring.
  • Improving processes to enable people to play a more active role. This could involve providing agenda setting sheets, that help people to think through what they want to get from an appointment; and providing people with test results in advance of the consultation, so they prepare questions in advance.
  • Refining IT systems and developing processes to support health care professionals. For example, in Ayrshire and Arran many GPs use the same system so they have developed a ‘tag’ for the records of people with COPD to prompt the GP to check if they have been offered a self-management programme.

Assessing readiness to change and commitment to supporting self-management within an organisation or team is important, and can be done using tools such as the Robert Wood Johnson Foundation assessment. Collaborative working between commissioners, service managers, professionals and people with long-term health conditions enables a shared understanding of challenges and identification of potential solutions.

Embedding processes that support self-management takes place gradually. Having clear goals, encouraging small changes, evaluating the impact of changes and making tweaks to processes as often as necessary before widespread implementation is important. There are a number of different quality improvement tools to support this, such as the Plan, Do, Study, Act cycle (PDSA). The process needs to include effective involvement of people with long-term conditions in the generation of ideas and design phases. This process will help to engage workforces at all levels, encourage ‘buy-in’ and a sense of ownership, and drive cultural change. In the longer term, it is important to evaluate the effectiveness of services and any changes made to assess how well they are meeting people’s needs.

Further reading

Patient and Family Centred Care Toolkit.

The King’s Fund.

Step-by-step guide to understanding people’s experiences of care and what needs to change www.kingsfund.org.uk/projects/pfcc

Quality improvement made simple.

Health Foundation.

A quick guide covering different QI approaches www.health.org.uk/sites/default/files/QualityImprovementMadeSimple.pdf

Co-producing services – co-creating health. 1000 Lives Wales
Report from Welsh project sharing learning www.1000livesplus.wales.nhs.uk/sitesplus/documents/1011/T4I%20(8)%20Co-production.pdf

Patient Leadership: the start of a new conversation. National Voices.

Introduction to Patient Leadership and co-production of change www.nationalvoices.org.uk/sites/www.nationalvoices.org.uk/files/patient_leadership_briefing_note_0.pdf

Ideas into action: Person-centred care in practice. Health Foundation.

Summary of key learning points from self-management implementation www.health.org.uk/sites/default/files/IdeasIntoActionPersonCentredCareInPractice.pdf

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