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National Service Framework Essay Constructing

The House of Care has been created out of a need to change the way we deal with long term conditions (LTCs).

The sheer scale of the LTCs challenge for modern healthcare systems means that we need a shift – away from the ‘medical model’ of illness (which worked efficiently in the 19th and 20th Centuries to bring down mortality and morbidity) towards a model of care which takes into account the expertise and resources of the people with LTCs and their communities. This will help to provide a holistic approach to their care and lives, and help them achieve the best outcomes possible.

The House of Care approach provides such a model.


The problem

The 15 million people in England with long term conditions have the greatest healthcare needs of the population (50% of all GP appointments and 70% of all bed days) and their treatment and care absorbs 70% of acute and primary care budgets in England.

It is clear that current models of dealing with long term conditions are not sustainable. Rather than people having a single condition, multimorbidity is becoming the norm. The number of people with three or more long term conditions is set to increase from 1.9 million to 2.9 million by 2018, and this will be associated with an extra £5 billion a year spend.

The barriers to great care for people with long term conditions have been identified by a wide range of reports and reviews, and can best be summed up as failure to provide integrated care around the person:

  • Single condition services: services dealing with single conditions only and adopting single condition guidelines (with attendant dangers of polypharmacy, and excluding a holistic approach to service users).
  • Lack of care coordination: people being unaware of whom to approach when they have a problem, and nobody having a generalist’s ‘bird’s eye’ view of the total care and support needs of an individual.
  • Emotional and psychological support: in particular, a lack of attention to the mental health and wellbeing of people with ‘physical’ health problems (as well as failure to deal with the physical health of people with mental disorder as their primary long term condition).
  • Fragmented care: the healthcare system remaining within its own economy, and not being considered in a whole system approach with social care or other services important to people with long term conditions (e.g. transport, employment, benefits, housing). Failure to support people with ‘more than medicine’ offers as provided by, for example, third and voluntary sectors.
  • Lack of informational continuity: care records which can’t be accessed between settings, or to which patients themselves don’t have access.
  • Reactive services, not predictive services: failure to identify vulnerable people who might then be given extra help to avoid hospital admission or deterioration/complications of their condition(s).
  • Lack of care planning consultation: services which treat people as passive recipients of care rather than encouraging self-care and recognising the person as the expert on how his/her condition affects their life.

Further information

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What people want

In order to design integrated care systems, people have told us that they want ‘person-centred, coordinated care’ giving the following narrative for how they manage their long term conditions:

“My care is planned with people who work together to understand me and my carer(s), put me in control, co-ordinate and deliver services to achieve my best outcomes.” (National Voices)

Person-centred, coordinated care enables people to make informed decisions that are right for them, and empowers them to self-care for their long term condition’s in partnership with health and care professionals.

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A solution – The House of Care

NHS England and partners are using the ‘House of Care’ model as a checklist/metaphor for these building blocks of high quality person-centred coordinated care. The House relies on four key interdependent components, all of which must be present for the goal, person-centred coordinated care, to be realised:

  1. Commissioning – which is not simply procurement but a system improvement process, the outcomes of each cycle informing the next one.
  2. Engaged, informed individuals and carers – enabling individuals to self-manage and know how to access the services they need when and where they need them.
  3. Organisational and clinical processes – structured around the needs of patients and carers using the best evidence available, co-designed with service users where possible.
  4. Health and care professionals working in partnership – listening, supporting, and collaborating for continuity of care.

The House of Care model (based on the Chronic Care Model of Ed Wagner, and the Diabetes UK Year of Care project) is useful for drawing together the building blocks of integrated care to include the essential elements of continuity:

  • Informational continuity: by which people and their families/carers have access to information about their conditions and how to access services; health and social care professionals will have the right information and records needed to provide the right care at the right time.
  • Management continuity: a coherent approach to the management of a person’s condition(s) and care which spans different services, achieved through people and providers drawing up collaborative care plans.
  • Relational continuity: having a consistent relationship between a person, family, and carers and one or more providers over time (and providers having consistent relationships with each other), so that people are able to turn to known individuals to coordinate their care.

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Applying the House of Care

The House of Care model is suitable for all people with long term conditions (LTCs), not just those with single diseases or in high risk groups,

and for frontline clinical practice, supported by local and national policy and strategy. There are at least three levels at which the House of Care modelcan be used:

Personal level: how the House of Care gives professionals on the front line a framework for what they need to do along with the people for whom they provide care and other providers, and ask local commissioners to secure for them (i.e. based around care planning discussions to jointly select the particular services which will help a particular person achieve their goals).

Local/community level: how can local health economies make sure that the House of Care involves a ‘whole system’ approach to provision of services, including ‘more than medicine’ offers (community links with social care, housing, transport, employment etc). This will need commissioners to decide on:

  • What: What are the principles and philosophy behind the care which commissioners wish to provide e.g. National Voices ‘I’ statements?
  • Which: Which populations of people with LTCs require a customised House of Care approach due to their particular care needs, and how will they be identified (e.g. risk stratification approaches, GP disease register, frailty index etc).
  • Where, When, and Whom: Decide the local model of care i.e. where and when will all the components of the House be delivered for each group of people, and by whom.
  • How: Write the specification of how to achieve this including the financial model that will support what needs to be done (tariffs, contracts, incentives etc that match the model of care).

National level: what national organisations such as NHS England and its partners do to enable construction of the House of Care (at the community and personal levels).

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Writing an academic essay means fashioning a coherent set of ideas into an argument. Because essays are essentially linear—they offer one idea at a time—they must present their ideas in the order that makes most sense to a reader. Successfully structuring an essay means attending to a reader's logic.

The focus of such an essay predicts its structure. It dictates the information readers need to know and the order in which they need to receive it. Thus your essay's structure is necessarily unique to the main claim you're making. Although there are guidelines for constructing certain classic essay types (e.g., comparative analysis), there are no set formula.

Answering Questions:  The Parts of an Essay

A typical essay contains many different kinds of information, often located in specialized parts or sections. Even short essays perform several different operations: introducing the argument, analyzing data, raising counterarguments, concluding. Introductions and conclusions have fixed places, but other parts don't. Counterargument, for example, may appear within a paragraph, as a free-standing section, as part of the beginning, or before the ending. Background material (historical context or biographical information, a summary of relevant theory or criticism, the definition of a key term) often appears at the beginning of the essay, between the introduction and the first analytical section, but might also appear near the beginning of the specific section to which it's relevant.

It's helpful to think of the different essay sections as answering a series of questions your reader might ask when encountering your thesis. (Readers should have questions. If they don't, your thesis is most likely simply an observation of fact, not an arguable claim.)

"What?"  The first question to anticipate from a reader is "what": What evidence shows that the phenomenon described by your thesis is true? To answer the question you must examine your evidence, thus demonstrating the truth of your claim. This "what" or "demonstration" section comes early in the essay, often directly after the introduction. Since you're essentially reporting what you've observed, this is the part you might have most to say about when you first start writing. But be forewarned: it shouldn't take up much more than a third (often much less) of your finished essay. If it does, the essay will lack balance and may read as mere summary or description.

"How?"  A reader will also want to know whether the claims of the thesis are true in all cases. The corresponding question is "how": How does the thesis stand up to the challenge of a counterargument? How does the introduction of new material—a new way of looking at the evidence, another set of sources—affect the claims you're making? Typically, an essay will include at least one "how" section. (Call it "complication" since you're responding to a reader's complicating questions.) This section usually comes after the "what," but keep in mind that an essay may complicate its argument several times depending on its length, and that counterargument alone may appear just about anywhere in an essay.

"Why?"  Your reader will also want to know what's at stake in your claim: Why does your interpretation of a phenomenon matter to anyone beside you? This question addresses the larger implications of your thesis. It allows your readers to understand your essay within a larger context. In answering "why", your essay explains its own significance. Although you might gesture at this question in your introduction, the fullest answer to it properly belongs at your essay's end. If you leave it out, your readers will experience your essay as unfinished—or, worse, as pointless or insular.

Mapping an Essay

Structuring your essay according to a reader's logic means examining your thesis and anticipating what a reader needs to know, and in what sequence, in order to grasp and be convinced by your argument as it unfolds. The easiest way to do this is to map the essay's ideas via a written narrative. Such an account will give you a preliminary record of your ideas, and will allow you to remind yourself at every turn of the reader's needs in understanding your idea.

Essay maps ask you to predict where your reader will expect background information, counterargument, close analysis of a primary source, or a turn to secondary source material. Essay maps are not concerned with paragraphs so much as with sections of an essay. They anticipate the major argumentative moves you expect your essay to make. Try making your map like this:

  • State your thesis in a sentence or two, then write another sentence saying why it's important to make that claim. Indicate, in other words, what a reader might learn by exploring the claim with you. Here you're anticipating your answer to the "why" question that you'll eventually flesh out in your conclusion.
  • Begin your next sentence like this: "To be convinced by my claim, the first thing a reader needs to know is . . ." Then say why that's the first thing a reader needs to know, and name one or two items of evidence you think will make the case. This will start you off on answering the "what" question. (Alternately, you may find that the first thing your reader needs to know is some background information.)
  • Begin each of the following sentences like this: "The next thing my reader needs to know is . . ."  Once again, say why, and name some evidence. Continue until you've mapped out your essay. 

Your map should naturally take you through some preliminary answers to the basic questions of what, how, and why. It is not a contract, though—the order in which the ideas appear is not a rigid one. Essay maps are flexible; they evolve with your ideas.

Signs of Trouble

A common structural flaw in college essays is the "walk-through" (also labeled "summary" or "description"). Walk-through essays follow the structure of their sources rather than establishing their own. Such essays generally have a descriptive thesis rather than an argumentative one. Be wary of paragraph openers that lead off with "time" words ("first," "next," "after," "then") or "listing" words ("also," "another," "in addition"). Although they don't always signal trouble, these paragraph openers often indicate that an essay's thesis and structure need work: they suggest that the essay simply reproduces the chronology of the source text (in the case of time words: first this happens, then that, and afterwards another thing . . . ) or simply lists example after example ("In addition, the use of color indicates another way that the painting differentiates between good and evil").

Copyright 2000, Elizabeth Abrams, for the Writing Center at Harvard University

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