Learning from those who are doing it

Since the publication of this blog Dr Martin McShane has left NHS England.

Dr Martin McShane, NHS England’s Director for Enhancing the Quality of Life for People with Long Term Conditions gives his views on the latest innovations in joined-up care.

The ambition for NHS England is to support delivery of high quality care for all.

Quality has been defined as a positive patient experience of safe and effective care. Effective care is itself defined as preventing people from dying prematurely, enhancing the quality of life for people who have long term conditions and helping people recover from episodes of acute care or trauma.

That sets out the background for the outcomes framework and the purpose of my job, as a Director, which is to provide clinical leadership for enhancing the quality of life for people with long term conditions.

One aspect of this role, which I find energising, is visiting communities that are tackling problems in an innovative and positive way.

Over the summer I have had the opportunity to see what is happening in three strikingly different communities, learn from them and reflect on how, at the centre, we can support what they are doing.

The first of these was in Newark and Sherwood where the CCG has used risk stratification to not only identify individuals who would benefit from support, but also to understand the needs of their population and check if services have been commissioned to address those needs.

I met the team tackling the problems people face with both single, but also multiple long-term conditions. General Practice, community teams, mental health, social care, the third sector and volunteers are working collaboratively. Their next step is to really change the way care planning is done.

This is the embodiment of what I call triple therapy: risk stratification, multidisciplinary working and personalised care planning. The feedback from those involved was positive. For professionals it made doing what they want to do, provide high quality care, easier and it was having a positive impact for individuals and carers.

A visit to Leeds showed me how communities can be mobilised alongside this approach. As I joined a short break in activities in a local community centre, people told me how having services, provided by the third sector, linked to health and social care, had transformed their lives.

Social isolation is on a par with smoking in its impact on health. We need to help stop it happening unnecessarily. The joint work by the CCG and Local Authority demonstrates the potential Health and Well Being Boards could have. I also found the aerobics session more demanding than I thought it would be…

My third visit was to Taunton where, once more the whole health and care system are working together to meet the challenges they face. What was tremendously exciting, for me, was to see the detailed analysis they had done, in partnership with York University, to join the data from different organisations and understand the impact the patient journey has on costs across the whole system. This ‘Symphony Project’ demonstrates the overwhelming importance and impact of co-morbidities and the need to have a person-centred rather than an episodic, condition specific, approach.

Reflecting on these visits I was encouraged that the approach we have been pursuing aligns with the problems communities are tackling in diverse geographies. We have adopted the metaphor of building a House of Care to deliver patient centred integrated care.

The foundations are commissioning (as a quality improvement cycle – not just contracting and procurement), which must support the two essential pillars of putting patients and carers in control and professional collaboration, capped by rigorous implementation of innovation and best practice.

On October 3 and 4, with UCL Partners, NHS England is staging the Future of Health conference in London to capture more examples and experience of building this new approach to improving the quality of life for people with long term conditions.

The response, so far, has been fantastic, with over 150 posters and case studies from across the country.

With patients and professionals, as a result of the dialogue and debate we aim to engender, I believe we will be able to capture and feedback the massive potential the NHS has to address the biggest problem health care systems face worldwide. I hope to see many of you there and continue to learn from the energy and commitment that people have to the values and purpose of the NHS.

For more details of the see the Future of Health conference website.

Dr Martin McShane was previously National Clinical Director for Long Term Conditions, since the publication of these blogs he has left NHS England.


  1. Terence Singleton says:

    Jane Cummings is correct, Nursing Care has the overall ability to improve a range of connected conditions, back pain, sciatica, depression and anxiety, freeing Physiotherapist to other work, whist reducing the traditional time of 9 sessions over 12 weeks by the new Nursing Practice, of relieving sciatica in one session. Simpler methods of contact with the Nursing Profession needs to be enacted NOW for innovation to be brought forward at a pace. Terence Singleton

  2. Lynne Craven says:

    When building ‘house of care’ please make sure patients are one of the architects….putting us at the centre means putting us at the beginning too!