“ENGLAND is too diverse for a ‘one size fits all’ care model to apply everywhere. But nor is the answer simply to let ‘a thousand flowers bloom’.”
This uncharacteristically poetic quote comes from NHS England’s Five Year Forward View, launched by chief executive Simon Stevens to much fanfare in October 2014. The document set out an overarching aim to dissolve the "traditional divide" between primary care, community services and hospitals – largely unaltered since the birth of the NHS – and introduce more personalised and coordinated care for NHS patients.
To this end the NHS invited organisations and partnerships to apply to become 'vanguards' in the development of new care models to act as blueprints for the NHS moving forward. Fifty such vanguard programmes now operate across England with enhanced funding.
The Symphony Programme is one such vanguard, set up as a collaboration between South Somerset GP Federation (19 practices), Yeovil District Hospital, Somerset Partnership NHS Foundation Trust and Somerset County Council. Together they serve a population of around 200,000 patients. One rural practice in the scenic market town of Castle Cary – Millbrook Surgery – has become an exemplar of the programme and the vanguard initiative.
I spoke recently to practice partner Dr Steve Edgar and manager Georgina Ball about the transformation taking place at Millbrook and in healthcare across the region. Steve has been actively involved with the Symphony Programme from the start and is currently its Chair.
"We’re a PACS vanguard [Integrated primary and acute care systems]," says Steve. "Working together with the hospital as a whole to help improve the healthcare system but not limited to that, so including social services, voluntary care and the wider community.
"A lot of what we’re doing is about putting back some of the good stuff that has been removed by the market changes. The ability of GPs in primary care to talk to their hospital consultant colleagues without somebody saying 'who’s billing who'. Trying to reduce that payment by item, by item and actually have people working for the system as a whole, and as a result working for that patient as a whole."
The Symphony Programme also aims to recognise "evolving needs", including rising patient numbers and a growing percentage with complex long-term health issues putting a strain on existing resources and services. Research by the Centre for Health Economics at York University in 2013 found that just four per cent of the population – those with multiple and complex conditions – account for 50 per cent of health and social care spend.
One innovation introduced by the programme to address these challenges has been the employment of "health coaches" to work alongside primary and secondary care in supporting people with complex needs. Health coaches are non-clinical practice staff who concentrate on prevention, care coordination and developing patients’ skills and confidence in self-management. This allows GPs to focus time more exclusively on clinical work.
"The idea was that they are people people," says Steve. "Closer to the demographic of the population than the professional might be so as to be able to facilitate communication. The reality is that a lot of the successful health coaches have been recruited from the HCA or the practice admin workforce. They’ve got a good understanding of the system already but want to take on more.
"Let’s say I see someone and they are going to start some medication. 'Here are the tablets; see you in a month’s time.' This person might need help with that treatment plan. We want it to stick; we want them to be more plugged into it. The health coach will go over it with them and then follow-up on a two-week interval. Bring them back in if there are any problems and just facilitate the plan so it makes a difference."
Health coaches also allow the practice to focus more resources on preventative care.
"We try to be as proactive as we can," says Steve. "That’s one of our metrics: how much of our care is because we initiated it. So with a health coach review – maybe it’s every two or three months – we call the patient and arrange a review, not waiting until something has gone wrong with them and then we are just playing catch up and firefighting."
Currently over 50 health coaches are now working across the Symphony Programme in 17 GP practices, supporting around 11,000 patients.
Another aim of the Symphony programme is to encourage more collaborative working, not just among practice staff but with the wider health and social care community. To this end, around three times a week, the practice convenes a "huddle" where the healthcare team discuss particular patient issues such as urgent care or emergency admissions, or "soft intelligence" such as missed appointments or other changes in a patient’s behaviour. All of the practice staff attend, as well as "outside" participants, including local "complex care teams" established to provide specialist care for patients with multiple and/or long-term health conditions.
"It’s a regular group of people but can be flexible and include hospice staff, mental health nurses or representatives from local voluntary organisations," says PM Georgina. "The huddles are completely health-coach-led. I don’t initiate the agenda at all. They have a database of patients on their radar, some who may be having interactions with the complex care team or have recently been in hospital. We talk about their care needs. We talk about shared learning. We talk about successful cases or perhaps things we could do better the next time."
Steve adds: "It really fosters a team ethos. It’s not just the GP’s job to do the work; it’s the whole team, led by the health coaches who reach into the hospitals. Some of our patients may be in hospital but they’re still our patients. We’re involved in their ongoing care."
Millbrook Surgery has three health coaches working with the GPs and practice staff, serving a growing list currently of around 5,500 patients. Another innovation at Millbrook aimed at fostering a team ethos is an open-plan office design where admin and clinical staff, health coaches and GPs all work next to each other, “hot desking” consulting rooms to see patients.
"Rather than the GPs being behind closed doors and the admin team hovering about trying to get an answer, we all work collaboratively together," says Georgina.
The practice also operates a unique appointment system called GP Access. They offer no pre-bookable GP appointments which puts the doctor completely in control of their day. Says Georgina: "patients can phone in and get an appointment and speak to a doctor on the day. This means our DNA rate is practically non-existent."
The changes implemented by Millbrook and the other practices in the Symphony Programme have yielded measureable improvements. In the last year, hospital overnight admissions in the region fell by 7.5 per cent, emergency bed days by 15 per cent and non-elective admissions from nursing homes by 50 per cent.
In May of this year the Symphony Programme was named ‘Primary Care Team of the Year’ at the BMJ Awards. The judges were impressed by the positive impact shown in developing patients’ skills, knowledge and confidence in self-management, and the programme team were praised for their focus on relationships, commitment to patient partnerships and strong measurable outcomes.
Now the task of the vanguard is to scale up the learning and the experience, says Steve. "To take some of the positive things we’ve managed to create and do that at a bigger scale so that it has a greater impact across the Somerset healthcare environment.
"When you talk about investment in primary care and bottom-up change it takes time to change and one of the lessons we’ve learned is to allow that to happen."
Jim Killgore is managing editor of MDDUS Practice Manager
Images above and eMonthly: Latitude Photography