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Transformational change in primary care

Transformational change in primary care

As primary care teeters on a knife edge, what are the radical ideas that can transform it? Heather Henry, chair of the New NHS Alliance, finds out
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The New NHS Alliance has a 20-year history of being a solution-focused primary care organisation that influences national policy, but 12 months ago, we changed that focus to addressing health inequalities. And to balance the current emphasis on preventing, treating and managing illness, we decided to explain another idea: how to create ‘wellness’. We believe that increasing steps can be taken to transform primary care as a force for public health by seeing people as the solution, rather than the problem.

The idea of health creation

We believe health creation is another string to the public health bow. It complements
a clinical model of health with a social one. It comes from three Cs:

• People feeling in control of their lives.

• Having meaningful social contact.

• Developing the confidence to improve their emotional and practical strength, knowledge and skills.

In our view, people and communities are assets and can find unique solutions to improve wellbeing that we as system and service leaders often cannot. Within the maelstrom of financial, political and operational pressures, the relationship between primary care and the communities they support to deliver person and community-centred ways of working can be further developed.

Living without hope

GP Dr Mark Spencer, whose practice is in Fleetwood, Lancashire, a town with considerable health challenges following the collapse of the fishing industry, recently explained on BBC Breakfast News that one of his main concerns was managing patients without hope. When this happens, he is often faced with frequent attenders who say ‘just give me the pills’. The link between physical and emotional health is inescapable, as is the link with disadvantage. People in these circumstances exist; they don’t live. He then talked about a socially isolated lady who attended the Healthier Fleetwood meeting to find new solutions to these issues. Dr Spencer explained that the default response might be a service solution, to offer befriending, or perhaps day care, which this lady did not want. Her solution was to use her skills to teach the young how to bake. This idea of a strengths-based view rather than a needs-based one is something that the health and care system is increasingly exploring.

Wigan deal

In Wigan, there has been a root-and-branch redesign to the council’s offer to the community, which it calls ‘the deal’. This is about having ‘a different conversation’ with patients, which focuses on their interests, strengths and personality. In NHS parlance, the whole discussion is about ‘what matters to me’, not ‘what’s the matter with me?’. In return the community is asked what it can do to help.

The deal was a response to the biggest budget cut the council had ever experienced – a £25m reduction from 2011/12 to 2015/16. Over the last four years, the council has reduced the number of day centres from 10 to five – transferring several to community ownership. They are on track to save a targeted £10m. Led by director of adult services Stuart Cowley and cabinet lead for communities Councillor Keith Cunliffe, they have transformed the way that adult services are delivered in Wigan and Leigh. Children’s services are now following.

Wigan council restructured and re-interviewed the whole of its social care staff and recruited for the values it wished to promote. It has trained over 1,800 staff in the last two-and-a-half years to focus on people’s strengths and passions, rather than assess for service delivery. People are connected to community initiatives that link to people-centred priorities, which might be a library initiative to teach an older person to use their iPad to keep in touch with distant family, or to reconnect someone to a much-loved hobby through a community needlework group. This resonates with NHS frameworks like care navigation and social prescribing, but the difference here is that there is a mainstream emphasis on recruitment to training to operational delivery, and an understanding that social connectedness and building on strengths is a vital part of the solution.

Realising the value

In a November 2016, NHS England and various partners published a report, Realising the Value.1 This wide-ranging report analysed in detail both the social and economic case for valuing the contribution that peers and communities can make. It gives an understanding of how people can change their lives using a social rather than a clinical approach. The report concludes: ‘We are waking up to the fact that the roots of health and wellbeing lie not in our hospitals, but in our communities’. 

It echoes the Wigan approach about person and community-centred ways of working being core to health and care business. It outlines 10 key actions to enable this to happen. Crucial among these is to see and engage the voluntary, community and social enterprise sector as a system partner.

The Realising the Value programme looks at five key approaches and gives real examples of how they work to transform lives. The five approaches are:

• Peer support.

• Self-management education.

• Health coaching.

• Group activities.

• Asset-based approaches.

The programme sets out the current ‘enabling mechanisms’ – existing legislative and delivery frameworks that help person and community-centred approaches to happen: things like personalised care and support planning, personal budgets, social prescribing and bridging roles such as health trainers and community navigators.

The economic case for health creation

Further, a second Realising the Value report2 presents an economic analysis of the case for investing in a more social approach to care. Their modelling suggests that implementing peer support and self-management approaches could equate to net savings of around £2,000 per person reached per year to the health system, achievable within the first year of implementation. For an average CCG, this equates to a saving of around £5m. For health coaching, group activities and asset-based approaches, there is less evidence available and thus the team has had to estimate savings to the health system, which they calculate are between £1,000 – £1,500 per person. An economic modelling tool is available to allow commissioners to estimate the cost benefit of each approach. This will allow a financial case for change to be built into sustainability and transformation plans (STPs).

Social enterprise as a public health solution

Back in 2011, a group of social entrepreneurs with personal experience of disadvantage in Scotland travelled to India to investigate how women had managed to get out of poverty by establishing self-reliant groups (SRGs). These are micro-credit schemes for people to start their own businesses. On their return, they started WEvolution (wevolution.org.uk).

In essence, the model is about people coming together and forming friendships and from this they each agree to save £1 a week towards starting their own business. They investigate their talents and strengths and start to use the funds they collect to buy materials to produce goods that might be needed in the area. This can range from simple crafts to things like clothing alterations.

In addition, the money collected can be used as a buffer against poverty by offering small loans using the power of peer pressure to make sure the loans are honoured. This prevents unscrupulous money-lending.

A survey of SRG members revealed the following benefits:

• Ability to borrow from the group.

• Chance to act as a role model within the community.

• Mothers relished the chance to get time for themselves.

• Ownership of the group.

• Sharing skills with peers.

• Knowledge and support to develop groups and products for income generation.

• Learning new skills from experts.

• Participants’ children seeing their parents work.

• Opportunity to socialise.

• Impact on the community.

• Space to dream big.

A report by the Yunus Centre for Social Business and Health at Glasgow Caledonian University has recently published a paper on this idea of social businesses being a way to improve health. It concludes: ‘It has been shown that social enterprises may impact upon physical health, mental health and the social determinants of health, whether or not they explicitly intend to do so’ – which means public health impact has been emergent rather than deliberate.

Introducing health creation as a way of transforming primary care

So far we have seen that:

• A more social, person and community-centred approach is gathering momentum.

• Although the evidence base is still developing, there is confidence that significant savings can be made.

• Economic modelling tools are available that federations of practices, vanguards, CCGs and those developing and implementing STPs can use.

• There are already a number of interventions being practised, such as health coaching and self-help groups, that help develop people’s control, contact and confidence (the 3Cs of health creation).

The key question now is how we take these ideas to the next level: to improve public health by creating health rather than preventing ill health and so reduce demand on a straining primary care system.

Changing the paradigm of service delivery

To do this, we need to change the way we think:

• We need to start to see people as a glass half full: to uncover their desires, strengths and skills and think how we
can help them fulfil their potential.

• This means shifting the culture of people from dependency and service entitlement to becoming part of the solution.

• From the perspective of primary care staff and commissioners, this means moving from a needs-led service delivery model to a ‘primary care as host’-type model, where we can create the conditions for people to flourish.

• We need to consider not only social but economic isolation and to find ways to help people become economically productive,  as a foundation to health.

Levers for change

Given the flux in political and financial systems, we need to consider where to start and what the potential levers are to encourage primary care transformation. One of the main levers is the GP contract itself and alongside that the opportunity afforded by the All-Party Parliamentary Group inquiry into managing demand in primary care where health-creating ideas might be put forward.

There is the opportunity to decommission or change the quality and outcomes framework (QOF) which is now quite unpopular with practices and introduce health-creating practices. In addition, there could be an evolution of the contractual requirement to have a patient participation group (PPG) to something that changes the emphasis on improvement in service delivery towards encouraging people (rather than just ‘patients’) to develop the concept of ‘surgeries without walls’: where the practice welcomes in the community and vice versa.

The twin challenges are:

• Changing mindsets of practices, people and communities towards the idea of practices as enablers of people-powered solutions, rather than leaders.

• Ensuring solutions reduce rather than increase practice workload.

Some existing ideas include:

• Social prescribing: this is now supported by a social prescribing network hosted by the University of Westminster.

• Altogether Better (altogetherbetter.org.uk), a volunteering programme to create practice champions who find people-powered solutions.

• Wellbeing Enterprises wellbeingenterprises.org.uk , which supports practices in Halton, Cheshire, by introducing a community wellbeing officer who offers people the chance to ‘talk, connect and take action’.

Some potentially new ideas include:

• Supporting members of the community, such as hairdressers and taxi drivers to become ‘antibiotic guardians’.

• Providing surgery space and encouragement for people to form self-reliant groups with the support of WEvolution.

• Identifying volunteers who are willing to share positive solutions via word of mouth within the community. ‘Eccles Together In Health’ in Manchester is one such project where seven practices co-produced solutions with local people. This included reading stories to children in assembly about going to the chemist rather than
the GP for minor ailments so as to increase the influence of ‘pester power’ in the home.

Case study: domestic abuse survivor

‘As a domestic abuse survivor and mother of five, who previously had very low self-esteem and zero self-worth, being a member of Alpacas SRG has added structure to my life. It has given me a purpose, a sense of ownership, and a support network of like-minded people.

Regularly meeting friends, sharing stories and learning new skills has added a new dimension to my life. I have discovered a productive outlet for my creativity, I have grown in self-confidence with every achievement I make. My support network has quadrupled. I can see that I have a worthwhile life and that there is a solid and constructive future for myself and my family. And most importantly, my children are proud of the mummy I am becoming.’

Heather Henry is a Queen’s Nurse and chair of the New NHS Alliance

References

1 Finnis A, Khan H, Ejbye J et al. Realising the Value: Ten Key Actions to Put People and Communities at the Health of Health and Wellbeing. London. NESTA. 2016

2 PPL. Impact and Cost: Economic Modelling for Commissioners. London: NESTA; 2016.

3 Plant M, Abel E, Guerri C. Alcohol and pregnancy. In: Macdonald I, editor. Health issues related to alcohol consumption. Blackwell Science; 1999.

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