We set out to address issues of feasibility, ‘could it be done’ and practicalities ‘how can it done’ in the real world of the NHS. It has successfully provided the practical evidence and support to achieve this.

Three pilot sites with diverse demographics, geographical and healthcare challenges were recruited to test the Year of Care approach in diabetes care. These were:

  • Calderdale, Kirklees and Huddersfield
  • North of Tyne
  • Tower Hamlets

Local clinical teams discovered that to achieve the best outcomes both systematic care and support planning and commissioning have to be in place and working together. They developed a practical and reproducible prototype and support and training programme to successfully transfer care and support planning to other sites.

There were a number of critical success factors. Where these were not present, the impact of the programme was diminished. These included:

  • Philosophy, attitudes and systems must all be addressed together to implement and sustain care and support planning
  • It must be clear where care and support planning fits into the local pathway or model of care for long term conditions and be an integral part of the local commissioning agenda
  • Staff need to be clear about their role if they are to fully participate and understand their role in care and support planning and support for self management
  • Local ‘champions’ both clinical and managerial are crucial; ‘right from the top, right from the start, right the way through’. GP champions are critical.
  • Local coordination and support to clinical teams is essential; delivered by people with  primary care experience, and a facilitative approach to partnership working
  • Training which links attitudes, skills and infrastructure change is essential
  • There are start-up costs and extra costs for people with poor health literacy but potentially significant gains to be made through service re-design and improved service utilisation
  • Care planning is about culture change and this takes time; staying in for the long haul delivers.

The Year of Care learning, now packaged by Year of Care Partnerships, enables new sites to get up and running more efficiently.

The Year of Care final report has further details of the key learning including some of the discoveries, dilemmas, debates and key challenges, and how these were overcome.