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The challenge:

Having successfully tendered to become one of three pilot sites implementing the Year of Care, NHS Calderdale and NHS Kirklees had to set about turning the theory into reality.

The aim:

The aim of the Year of Care programme is to learn how routine care can be redesigned and commissioned to provide a personalised approach for people with long term conditions.

What did they do?

Following their successful application to become a pilot site, each PCTs Diabetes Network was enlisted so that the Year of Care model could become integral to and support their plans for diabetes service redesign. Service redesign plans included providing level 1 to 4 care in primary care, with level 5 care being offered at in secondary care settings. This model sits well with the Year of Care aims. Funding beyond the £98,000 provided by the pilot for the first year was agreed between the two PCTs and the local foundation trust. Dedicated staff were identified, including a full-time project manager and part time administrative and project support. In Kirklees this project was supported by a financial incentive scheme (FIS) which helped to recruit practices to the pilot.The project team spent the first year of the pilot ensuring practices were fully trained to undertake care planning. This began with practice teams attending a half day session to help them to identify what steps they needed to take to implement care planning. The FIS for 2009 required that practices attended a half day National Year of Care awareness training session and in 2010 the FIS required staff to attend full National Year of Care training and submit 25 percent of their care plans.

What happened?

Full national care planning training has been rolled out to 80% of practices in NHS Kirklees. It is too early to assess the impact of the project, however some positive, unintended consequences include:

• The care planning training provided an opportunity to re-launch a local self-care handbook and web pages and provided a platform to market the local Health Trainer Team.
• The care planning process became the lynch-pin of the service redesign, rather than just supporting it.
• Care planning training was extended to include all community and primary care staff (district nurses; community matrons etc) as well as health care assistants.
• Introducing the care planning training across the whole of community and primary care has assisted multi-agency working and improved communication.