Commissioning for personalisation in stroke prevention: The DDES experience
Made up of 42 GP practices covering southern and eastern County Durham unitary authority, Durham Dales, Easington and Sedgefield (DDES) Clinical Commissioning Group has a registered population of 288,000. GPs and a multidisciplinary leadership team of health professionals are fully responsible for the planning and purchasing (commissioning) local health services.
In January 2012, DDES CCG started working with Boehringer Ingelheim Limited (BI) and the social business GCA Limited to co design a prototype stroke prevention commissioning programme for spread across the UK.
The aim of the programme was to explore and deeply understand peoples’ current experiences of stroke prevention so that DDES can improve personalisation of care and commissioned services and develop a set of sensitive measures to track improvement.
This work consisted of 4 stages:
Developing insight and completing need assessment: DDES engaged commissioners, front line caregivers (NHS, social care and voluntary sector), local people with experience of stroke and stroke prevention and their families in 2 events and undertook 10 semi structured interviews with local people and caregivers to map current stories and experiences of stroke prevention and desired ones. This threw up anomalies about how care givers and people/families see the world and a set of improvement challenges around personalisation. Most notable was the contrasting professional/patient and family experience of ‘hearing diagnosis and early support’. DDES data was then benchmarked with National ELC™ insights and then triangulated to provide a comprehensive health needs assessment.
Service specification: the co design process continued with two full day events. The first applied PATH planning. Local people worked with commissioners/caregivers to co design ‘great stroke prevention care in three years time’ and a detailed route map. The second brought stakeholders together to co design solutions to the 12 most critical improvement challenges and develop a three year strategy.
Improvement contract co design: current providers, local people, providers and commissioners co designed an improvement contract framework, including: a shared ‘purpose’ and a set of person centred values to drive commissioning/service delivery; outcome measures that all providers – including voluntary sector, lifestyle services, GP, pharmacy and NHS trust providers – will be held to account for and that can underpin an integrated ‘alliance contract’ for personalised stroke prevention care.
- Improving family and personal experience of hearing diagnosis and early signposting peer support ( largely in general practice) to accelerate restoration of peoples’ confidence and ability to reduce their risk and improve their lives independently (what they want);
- Systematising primary care screening and follow up in high risk people;
- Commissioning an integrated ‘connection’ experience in the form of an invigorated, more focused network of peer led support groups (mainly voluntary sector) for people with risk factors for hypertension, stroke, including CVD, diabetes, AF and TIA
- Commissioning personalised exercise programmes that build confidence in the person AND their spouse to keep exercising as they did prior to diagnosis
- Integrating pharmacy commissioning to deliver ‘confidence about managing my medicines’
- Educating caregivers so they empathise with people and better understand how stroke prevention impacts on people and family lives
Educating ‘gatekeepers’ (GP receptionists, out of hours, A&E) about stroke symptoms so they accelerate access to diagnosis and treatment.
DDES deeply understands the improvement challenge and can commission the right services and measure the outcomes that matter. The work was endorsed by DDES CCG’s authorisation team.
- Stroke prevention, diabetes and cardiovascular disease prevention have much in common. We can rationalise experience led commissioning around these agendas
- Clinicians grossly underestimate the impact of TIA and AF on people lives. People tell us ‘it feels like you are dying’. Clinicians say, ‘It won’t kill you’. When a clinician has first hand or close family member experience of living with these conditions, their attitude quickly changes and they deliver more empathetic care
- Peoples’ experience of hearing diagnosis and early support to come to terms with and adjust to a new way of living can either accelerate their ability to self care and prevent stroke or leave them feeling disempowered, anxious, scared, helpless and with no confidence to take action. Confidence is essence of what people need to feel to improve stroke prevention outcomes
- Peer support and being connected with people who share the same experience is a great comfort and vastly undervalued by health commissioners. In stroke prevention, which largely relies on self care, it is as important as clinical care.
- Front line care givers and people alike find participation in ELC™ co design events is a learning experience.
Commissioning can be inspiring, fun and educational!