Year of Care Improving the care of people with diabetes and providing a framework for personalised care in long-term conditions

Aims

The Year of Care programme aimed to take a new look at the relationship between people with long-term conditions and the NHS, using diabetes as an exemplar. The longer term goal was to enable patients to manage their own conditions and reduce the burden on the NHS in terms of avoidable admissions, ambulance call-outs and A&E costs.

Training was given to develop care planning consultation skills (using the appropriate implementation tools), allowing clinicians and patients to work together to create packages of care that were personal to the patient. Once developed, care plans were regularly reviewed.

Outcomes

• Care planning was adopted in a majority of practices across the pilot communities.
• 76% of people with Type 2 diabetes on practice registers had at least one care planning consultation.
• 1,000 health care professionals were trained.

Benefits

• People with diabetes reported improved experience of care and real changes in self care behaviour.
• Professionals reported improved knowledge and skills, and greater job satisfaction.
• Practices reported better organisation and team work.

Learning

The Year of Care programme found that care planning was a huge cultural change for organisations and those involved, with success depending on:

• commitment to care planning right from the top, right from the start
• support for reorganisation of routine diabetes care from clinics and administration teams
• robust training linked to practical approaches
• support for those adopting this approach.