Under each of these themes we have detailed the outcomes we want to see for patients, and set out the most important priorities for action to achieve these outcomes.
Linked to these outcomes, we have selected the service improvements that, if met, will have a major impact on the quality and cost-effectiveness of care. These are by no means the only service changes that are needed to achieve the outcomes we would like to see, but we believe they are the most urgent and important. These are the things we can, and must, get on and do.
People feel that the care they receive is seamless because it is organised around them and their needs.
Everyone with long-term care needs that require a health or social care response should be guaranteed a written care plan encompassing health, social and preventative care, and the right to access a named care co-ordinator of their choice if they wish to. Patients need to be supported to lead the development of a care plan, understand it, and have confidence about who to approach when they need support.
Services reflect the needs of patients because patients and carers are meaningfully involved in service commissioning, planning, design and improvement.
Clear accountability is needed to ensure effective and meaningful patient involvement in both the commissioning and provision of services.
People with long-term conditions can manage their condition appropriately because they have the right knowledge, resources and support.
People with long-term conditions should be offered and have access to a range of flexible, responsive self-management support including tailored information and advice and structured programmes to help them manage their condition successfully.
Everyone is supported to lead as active and healthy a life as possible. People should also be supported to access services early to reduce or prevent episodes of crisis.
Commissioners and providers should use tools such as risk registers to proactively find people at high risk of developing chronic and life-threatening conditions or complications from existing conditions, and offer them targeted screening and other interventions to encourage behaviour change.
We also believe patients who have spent time in hospital need to be followed up and supported in the community to ensure rehabilitation and re-ablement, and need to be supported to have greater control over accessing services at points of crisis.
Everyone with long-term care needs, whether mental or physical, can access appropriate emotional, psychological and practical support to improve their health and well-being.
Emotional, psychological and practical needs should be routinely assessed during the care planning process to support facilitated access to services where this is needed.
In addition to this, health and social care commissioners must be accountable for ensuring that individuals with long-term care needs have the opportunity to access appropriate emotional, psychological and practical support.
Our Doing the Right Thing project comprises a programme of evidence-based influencing designed to shape health and care system reform linked to the NHS Five Year Forward View and other key change agendas, by showcasing the voluntary and community sector’s (VCS) value add.
Richmond Group members and other key partners (Mind, Royal Voluntary Service, British Red Cross and Public Health England) have worked with New Philanthropy Capital (NPC) to examine dozens of evaluations of our interventions to evidence where the VCS adds value to patients and users, and the system.
The report and executive summary are the result of the evidence review and workshops, focus groups and interviews with system leaders, through which we developed frameworks for understanding the VCS’s contribution to the health and care system, and examining the barriers and enablers to VCS involvement.