The House of Care: Re-imagining primary care in Scotland
Summary: the problem
- Focus within Scottish general practice on single disease processes and meeting seemingly-arbitrary targets meant patients felt as though their care was fragmented.
- This focus also impacted staff morale: staff reported feeling feel burnt-out and disillusioned, which can affect recruitment and attrition.
- Absence of strategic vision for primary care resulted in piecemeal policies that acted as band-aid solutions, without creating lasting change.
- “House of Care” is a sequence of several interrelated, synergistic strategies, at the core of which is a patient-led care programme design.
- Patients design their own care plan in consultation with practice nurses.
- Patients report having more agency. Some patients report an improvement in biomedical markers, as well as overall wellbeing.
- Staff morale appears to have increased.
In Scotland, as with similar countries, the proportion of the population affected by multi-morbidies and chronic health conditions continues to increase. However, the current primary care model focuses on the management of a single disease condition. A silo-based approach meant that care for patients with multiple co-morbidities and complex biopsychosocial needs was fragmented. Patients felt ill-equipped to handle their own needs because of a combination of factors, including poor health literacy, and a perceived lack of support from medical professionals. At the same time, this system reduced morale amongst staff and contributed to burn-out. This resulted in dissatisfaction for patients and staff alike.
“House of Care” is a visual metaphor, which emphasizes the importance of a number of interdependent strategies in order to develop people-centred primary care services. In practice, it consists of a number of interdependent strategies: simplifying organisational/administrative processes and arrangements; improving health literacy for patients and carers; increasing collaboration across and within healthcare teams; increasing collaboration between formal and informal sources of support in the community; and a patient led “care and support planning conversation.”
The latter is the lynchpin of this model. Initially, patients receive a full screening at the initial consultation. They receive the results of this screening in a readily-understandable format, in advance of the second consultation. The second consultation involves the patient developing their care plan in partnership with a healthcare professional (usually a practice nurse.) The patients set their own health priorities during this consultation, and also feel able to discuss psychosocial aspects of their lives. This gives them a sense of agency. In order to facilitate this model, the following infrastructure has been put into place: training for healthcare professionals in long-term support and planning; systematic process of planning; and forming linkages to support services within the community. It is based on the principle of co-production, namely, the idea that the patient and healthcare professional alike each bring to the planning meeting their own perspectives, priorities, and expertise.
The role of the patient’s wider community in their well-being is of particular importance within this model of care. This is facilitated through "A Local Information System for Scotland" (ALISS) - a collaborative search engine through which patients can share and find information about local support services, such as walking groups and support groups for carers.
This model can inform and structure the provision of services not just within the context of an individual clinic, but on a regional and ultimately national level too. At all levels, it maintains the collaborative conversation between stakeholders at its core.
The Health and Social Care Alliance Scotland (the ALLIANCE) is directing a programme working with three early adopters, mentioned above, as well as a further two mid-adopter sites – Lanarkshire and Ayrshire & Arran. Implementation is led locally with centralised co-ordination.
Funding for the programme has been identified from within the person-centred and quality team and primary care team of The Scottish Government. This is in addition to funding from the British Heart Foundation.
Each site is making good initial progress:
Of the early adaptors, Tayside, has increased uptake of the "Year of Care Partnerships Care & Support Planning" (CSP) training amongst a variety of health professionals including GPs, nurses and diabetes consultants.
Staff in over 30 practices in Glasgow have now undertaken this training. Lothian has included adoption of the House of Care model as part of their longer term strategic plan for service redesign and improvement. Each of these sites has received additional funding from the British Heart Foundation to support work more directly focused on Cardiovascular Disease. This funding has come with a helpful focus on robust evaluation.
Additional resources from the Primary Care Development Fund have supported the spread and learning from the early adopter approach to two more areas: Lanarkshire and Ayrshire & Arran. Ayrshire is delivering the CSP training to practices throughout the country, meanwhile the HoC work is embedded within Lanarkshire’s organisational change programme, resulting in more practices receiving the relevant training.
Moreover, patients and staff alike report positive changes. Patients report feeling empowered, feeling more inclined to be proactive about their health, and having a perception that healthcare professionals are meaningfully engaged in their care. One patient states “you feel as if you’ve got the whole control of your life and your health and your wellbeing.” Additionally, staff report feeling more fulfilled by their work and having more satisfaction. One GP noted that this model has enabled him “to have that relationship with patients that I wanted to have when I went into general practice.”
The Royal College of General Practitioners, both at a Scotland and UK level, are strongly committed to supporting developments in Collaborative Care and Support Planning, viewing it as fundamental to the change required to address the current crisis in GP services. Their Blueprint for Scottish General Practice and 2016 Manifesto make explicit mentions of their support for the House of Care programme in Scotland.
This buy-in from clinicians is key to the success and so represents very positive endorsement. Positive discussions are on-going on how the approach can provide a coherent, integrative model supporting the wider aims around person-centredness and health and social care integration, and how this links to ensuring the strategic role of the third sector. This has promoted connections across the Scottish Government with policy areas including primary care, integration, mental health, self-directed support, self management, health literacy and public health.
Scottish Government: The Health and Social Care Alliance