There is a growing amount of evidence and reviews that look at the different elements of taking a personalised, aligned and holistic approach to the management of care for patients with long-term conditions.  Each of these different elements have an impact on clinical indicators, patient satisfaction and their feeling of being involved in their care.

One problem that we noticed, when investigating the evidence, is that there is a lack of consistency amongst organisations in terms of providing professionals with the required skills to really embed the different elements and to implement and measure the impact.

To our knowledge, the Aligned Care Programme is unique, in that it combines many of these different elements into one programme to provide the health professional with the skills to develop their consultation approach and combine the benefits of the individual elements.

This page is intended to provide a sample of the evidence and reviews of these different elements for your perusal. Where appropriate, we have provided links to the full details for further information.

Personalised Care

In the NHS Long Term Plan published in 2019, personalised care was one of the five major, practical changes that were highlighted with the target of rolling out personalised care to 2.5 million people by 2023/24. This followed a decade of evidence-based research working with patients and community groups. As an example, from tracking over 9,000 people with long-term conditions across a health and care system, evidence has shown that people who are more confident and able to manage their health conditions (that is, people with higher levels of activation) have 18% fewer GP contacts and 38% fewer emergency admissions than people with the least confidence.
NHS England state that: “The evidence base for personalised care continues to grow, demonstrating a positive impact on people, the system and professionals. Shared decision making between people and clinicians about their tests, treatments and support options leads to more realistic expectations, a better match between individuals’ values and treatment choices, and fewer unnecessary interventions.
Personalised care also has a positive impact on health inequalities, taking account of different backgrounds and preferences, with people from lower socioeconomic groups able to benefit the most from personalised care” https://www.england.nhs.uk/personalisedcare/evidence-and-case-studies/

The House of Care

The House of Care model was created out of a need to change the way we deal with long-term conditions:
“The sheer scale of the LTCs challenge for modern healthcare systems means that we need a shift – away from the ‘medical model’ of illness (which worked efficiently in the 19th and 20th Centuries to bring down mortality and morbidity) towards a model of care which takes into account the expertise and resources of the people with LTCs and their communities”
“The 15 million people in England with long term conditions have the greatest healthcare needs of the population (50% of all GP appointments and 70% of all bed days) and their treatment and care absorbs 70% of acute and primary care budgets in England. It is clear that current models of dealing with long term conditions are not sustainable. Rather than people having a single condition, multimorbidity is becoming the norm.”
“My care is planned with people who work together to understand me and my carer(s), put me in control, co-ordinate and deliver services to achieve my best outcomes.” (National Voices)
The House of Care framework holds person-centred coordinated care at its centre with engaged, informed individuals and carers and health care professionals committed to partnership working as the walls of the house. The Aligned Care Programme fill the skills gap in health professionals implementing the house of care model
https://www.england.nhs.uk/ourwork/clinical-policy/ltc/house-of-care/

Patient Experience

https://www.nice.org.uk/guidance/cg138/chapter/1-guidance
“Patients value healthcare professionals acknowledging their individuality and the unique way in which each person experiences a condition and its impact on their life.
Patients’ values, beliefs and circumstances all influence their expectations of, their needs for and their use of services. It is important to recognise that individual patients are living with their condition, so the ways in which their family and broader life affect their health and care need to be taken into account.”
“Patients wish to be seen as an individual within the healthcare system. This requires healthcare professionals to recognise the individual, and for services to be tailored to respond to the needs,preferences and values of the patient. Advice on treatments and care, including risks and benefits, should be individualised as much as possible.”
“Adopt an individualised approach to healthcare services that is tailored to the patient’s needs and circumstances, taking into account their ability to access services, personal preferences and coexisting conditions. Review the patient’s needs and circumstances regularly.”
“Hold discussions in a way that encourages the patient to express their personal needs and preferences for care, treatment, management and self-management. Allow adequate time so that discussions do not feel rushed.”
“Continuity and consistency of care and establishing trusting, empathetic and reliable relationships with competent and insightful healthcare professionals is key to patients receiving effective, appropriate care.”

CQC Requirements

See the summary article by Dr Devin Gray and Dr Deborah Kirkham from October 2016 at
https://www.medeconomics.co.uk/article/1412705/cqc-essentials-personalised-care-support-planning
In this article they state that:
“CQC inspectors will want to see evidence that people who use the practice and those close to them are involved as partners in their care and care plans will be a key part of this.”
Personalised care and support planning addresses the holistic needs of an individual patient, including physical and mental health and care needs.
More than 15m people in England are living with a long-term condition (LTC) and a rising number have multiple LTCs. Yet they only spend a few hours per year with health and care professionals; the rest of the time is spent self-managing their condition.
People who are engaged in their health and care are more likely to receive care and treatment that is appropriate to their needs, to adopt healthier behaviours, and less likely to use emergency care.
On their inspections of GP practices, CQC inspectors want to see evidence that people who use services and those close to them are involved as partners in their care”

What patients want

An article was published in the Nursing Times by Tracy Morton and Maureen Morgan examining how personalised care planning can help patients with long term conditions
https://www.nursingtimes.net/clinical-archive/long-term-conditions/examining-how-personalised-care-planning-can-help-patients-with-long-term-conditions-17-09-2009/
In this article they state that:
“People with long-term conditions have told the Department of Health that they want services that help them remain as independent and healthy as possible.
They also want quality information to help them understand and manage their conditions better and support wider choice. Patients have also indicated that they want more services delivered safely and effectively in the community or at home, with more proactive and integrated services personalised to them and their needs (Opinion Leader Research, 2006; DH, 2005a).”
“Many benefits can be gained from personalised care planning. International evidence shows best outcomes are achieved when there are: systematic proactive services; people engaged in their own care; and healthcare professionals and people with long-term conditions working in partnership (Wagner et al, 1996).”
“People who feel more confident to manage their own health tend to feel more confident in their everyday lives and therefore have a higher quality of life. They also tend to have improved clinical outcomes (Newman et al, 2004). Supporting people to self care through care planning can reduce GP visits by 40% for high-risk groups (Fries and McShane, 1998) and reduce hospital admissions by 50% (Montgomery et al, 1994).”

Personalised Care Planning

Angela Coulter, Vikki A Entwistle, Abi Eccles, Sara Ryan, Sasha Shepperd and Rafael Perera searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, ProQuest, clinicaltrials.gov and WHO International Clinical Trials Registry Platform to July 2013 to assess the effects of personalised care planning for adults with long‐term health conditions compared to usual care (i.e. forms of care in which active involvement of patients in treatment and management decisions is not explicitly attempted or achieved). They included 19 studies involving a total of 10,856 participants. Although results on clinical indicators were varied, the following is of note:
Nine studies measured glycated haemoglobin (HbA1c), giving a combined mean difference (MD) between intervention and control of ‐0.24% (95% confidence interval (CI) ‐0.35 to ‐0.14), a small positive effect in favour of personalised care planning compared to usual care.
Six studies measured systolic blood pressure, a combined mean difference of ‐2.64 mm/Hg (95% CI ‐4.47 to ‐0.82) favouring personalised care.
A single study of people with asthma reported that personalised care planning led to improvements in lung function and asthma control.
Nine studies looked at the effect of personalised care on self‐management capabilities using a variety of outcome measures focussing primarily on self efficacy. They were able to pool results from five studies that measured self efficacy, giving a small positive result in favour of personalised care planning: SMD 0.25 (95% CI 0.07 to 0.43).
A further five studies measured other attributes that contribute to self‐management capabilities. The results from these were mixed: two studies found evidence of an effect on patient activation, one found an effect on empowerment, and one found improvements in perceived interpersonal support.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD010523.pub2/full

The impact of Motivational Interviewing

There is still work to be done on carefully assessing the evidence on the impact of motivational interviewing on health management, yet the following have produced some interesting findings:
https://pubmed.ncbi.nlm.nih.gov/22209215/
shows a study based in Taiwan in which showed findings providing important evidence concerning the positive effect of motivational interventions in self-management, psychological and glycemic outcomes.
https://www.sciencedirect.com/science/article/abs/pii/S0738399115301373
concludes that: “The effects of MI interventions on outcomes in T2D (Type 2 Diabetes) showed promising results for dietary behaviors. Clinical change outcomes from MI-based interventions were most favorable for weight management in T2D.”
https://www.bmj.com/content/307/6897/188.abstract
In this article by Stephen Rollnick, Nigel Stott and Paul Kinnersley they look at the limitations of giving advice when it comes to helping people change behaviours in relation to eating, drinking, smoking, exercise or taking medication. They state that “The main limitation of giving advice about lifestyle is that the evidence of its effectiveness is not very convincing. One the one hand, it is clear that brief interventions for behaviours like smoking and heavy drinking has some benefit, in the sense that recipients of brief advice fair better than their counterparts in control conditions. On the other hand, it is also apparent that the size of the effects of treatment in these studies is fairly small, with success rates of 5-10% not uncommon. Thus, whilst some patients seem to respond to advice, most do not.”
https://www.sciencedirect.com/science/article/abs/pii/S1499404606005872
This study looked at whether training dieticians in MI (Motivational Interviewing) had an impact on their counselling style and resulted in lower saturated fat intakes in their patients and concluded: “MI dietitians were significantly more empathetic, more often showed reflection during consultations, and were more likely than control dietitians to let their patients talk for the majority of the consultation. Patients of MI dietitians had significantly lower saturated fat intake levels at post test compared to patients of control dietitians.”
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