collective voice

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Taking the pain out of long term conditions

November 11, 2016 09:20

Everyone agrees that we need to take a patient centred approach to long term conditions management and lifestyle behaviour change.

Increasingly, we see lifestyle services being integrated (including smoking, weight management and alcohol) to provide a more joined up and holistic offer to people, with improved two way dialogue with primary care to support people with long term conditions.

All our insight research over the past decade or so has consistently shown that this is what patients and the public want. However, to do this effectively, we need to understand the needs of the system in a very different way. It’s not enough to understand the drivers; we need to drill down and identify the outcomes that would be expected across the whole system if it is to adopt a truly patient centred approach.

This means designing an approach that will deliver evidence of patient centred outcomes - these are unlikely to be clinical markers. Rather, they will be things that really matter to the patient. But we still have to be mindful of health care professionals’ desired outcomes – aligning with targeted clinical measures as well as softer measures such as patient experience.

In order to achieve this, we have to change the way that we work. The ICE excellence model effectively does this, moving us away from a culture of design in isolation and market test, to one of co-creation and collaboration.

The model follows a systemic approach by bringing all of your stakeholders together to co-design the future state. This places the patient at the very centre of the work and designs with them in mind, while also ensuring the needs of the wider system are met.

We involve the people in the system in every step of our programme design. In doing so, we make them true designers of the future, rather than validators of previous thinking.

Being outcomes focused, the model concentrates on values, beliefs and behaviours and supports a truly patient centre approach. This ensures that we design for the whole system - which is crucial in supporting patients to become engaged with their own health and condition management.

Supplementing the ICE excellence model, ICE’s health and wellbeing digital platform Puffell is an effective and evidence-based solution to achieve a truly patient centred approach to managing long term conditions and changing lifestyle behaviour. Puffell creates and delivers a lifestyles-based ecosystem that offers a targeted and universalistic approach for building greater wellbeing and resilience for society.

Puffell supports people at their point of need by understanding what’s important to them as individuals and building behaviourally-focused activation. Puffell then uses both technology and peer support to maintain that choice until it is habit formed.

Designed around the evidence and disciplines from behavioural science, cutting-edge digital solutions and strategy from the 9 wider social determinants of health, Puffell also empowers people by engaging the power of the 5 ways to wellbeing - connect, get active, be positive, learn new things and enjoy the power of giving.

Simple to use, beautifully designed and user friendly, Puffell has the power to build a society that is resilient, well and HAPPY.

Before designing and developing Puffell, we conducted a piece of insight that told us 7 things:

  1. People don’t understand/recognise their health and implications of poor health long term
  2. People want to do more for themselves but don’t know where to start
  3. People feel ‘frustrated’ and ‘abandoned’ – and the health system misses key opportunities to engage with the right tools
  4. People want to be treated as a ‘whole person’
  5. A plea - use channels that we use
  6. Lack of trust in government
  7. People have great aspiration - they want better, although they struggle to define what better is for themselves, yet they can almost always describe it to others who are important to them.

By building Puffell based on insight, we are also able to collect meaningful hard and soft data for individual areas:

  1. Clinical measures - which evidence that a patient or citizen has made positive progress
  1. People-centred outcome measures (PCOMs and PROMs) - a relatively new concept which involves putting patients, people, and their families and carers at the heart of deciding which goals are most valuable for individuals with a range of health conditions, rather than clinicians deciding what is best.

The data we are collecting is now evidencing outcomes, including: 

  1. Increased patient self care
  2. Better citizen self-management
  3. Reduced and redirected service demand
  4. Reduced health and social care costs via prevention and better managed conditions.

Joined up lifestyle services are now using Puffell to case manage clients and support them both online and offline – you can too!

To find out more about how Puffell can act as a lever of system change in your area, contact Richard Forshaw-Smith at or on 0845 5193 423.