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Enhancing primary care

Enhancing primary care
22 April 2016

Simon Stevens' vanguards are now well under way. Fylde and Wyre and Blackpool’s local services have pulled together and created new models of care for its seaside population

Simon Stevens' vanguards are now well under way. Fylde and Wyre and Blackpool’s local services have pulled together and created new models of care for its seaside population

The picturesque boroughs of Fylde and Wyre and the historic seaside town of Blackpool are collectively referred to as the Fylde Coast, with a combined population of more than 320,000.
The development of new models of care on the Fylde Coast is an ambitious transformation programme. It is designed to ensure that health and social care services for the people of the Fylde Coast are integrated to provide better care outside of hospital and that parity of esteem is achieved between physical and mental health needs.
The challenge we face across the Fylde Coast is significant. While the health of our residents is generally improving, it is still worse than England’s average. Blackpool is still England’s largest and most popular seaside resort attracting 11 million visitors annually. There is a considerable amount of transience, including movement in and out of the town, as well as movement within it. This, coupled with high unemployment and rising prevalence of long-term conditions, has led to significant levels of deprivation and health inequalities that rank among the worst in the country. Blackpool has the worst life expectancy in the country for men and the third worst for women. Within the most disadvantaged areas of Blackpool men can expect to live 13.3 years and women 8.3 years less than people in the least disadvantaged areas. Not only do people in Blackpool live shorter lives, they also spend a smaller proportion of their lifespan in good health and without disability. In the most deprived areas of the town disability-free life expectancy is around 50 years.
In contrast, 57% of the population in Fylde and Wyre live within two of the most affluent quintiles. But, there are more than 16,800 people living in neighbourhoods that are classified as being among the fifth most disadvantaged areas in England, with men dying on average, 10 years younger than those in more affluent areas. For women, the difference is six years. A higher percentage of people in Fylde and Wyre are affected by long-term health problems than the national average. These include diseases of the heart and blood vessels, diabetes, kidney disease and stroke. The number of people with dementia is higher than the national average.
It is predicted that the number of over-65s within the whole Fylde Coast population will rise to between 31% and 35% by 2028.

Pulling together
To respond to these challenges, both Fylde and Wyre Clinical Commissioning Group (CCG) and Blackpool CCG joined forces with local care providers, Blackpool Teaching Hospitals NHS Foundation Trust, Lancashire Care NHS Foundation Trust, Blackpool Council and Lancashire County Council to begin the development of new models of care in early 2014.
As partners we recognised that continuing to deliver more care in its current form is not financially sustainable. We know more people are cared for in hospital than is necessary and that care can be provided more effectively in the community or at home. The care we provide is not always as coordinated as well as it could be and this can lead to poor experiences for patients and their families.
We reviewed successful models of care from America and Europe and undertook an analysis of how these could be implemented to meet the needs of our local population and of the wider health and social care system in the UK. During the development of the CCGs’ five-year strategies, our vision was advanced and tested by extensive engagement with a wide range of partners, patients and the public. Hearing their experiences of local services has helped to shape how our new models of care look.
Our response was to develop approaches to extensive care and enhanced primary care. These are founded on identifying distinct cohorts of patients by using a risk stratification tool, who are then supported and enabled by fully integrated teams. To do this we are bringing health, social and third sector services together to be based within primary care on geographical neighbourhood footprints.

Models of care
Our models include the development of a unique role – a health and wellbeing support worker. These individuals are a consistent feature throughout. The wrap around support and lead practitioner may change as the tailored care is adjusted to reflect changing needs but the health and wellbeing support worker will stay with the individual patient throughout their journey of care until they are stabilised or no longer benefit from the new model of care.
Contact with the health and wellbeing support worker will be re-established should needs change or conditions deteriorate and the individual is recommended for inclusion in the new model of care system in the future. The health and wellbeing support worker will develop an in-depth understanding of the individual through their regular contact, and tailor their one-to-one support accordingly. This will be wide-ranging and may include; reminders to attend appointments and take medication; act as an advocate; accompany to activities such as wellbeing exercise sessions; encourage new interests and hobbies and confidence building etc.
The Fylde Coast is reflective of nearly all health systems in that a substantial proportion of the healthcare budget is accounted for by relatively few patients, many of whom have long-term conditions, are elderly/frail or have serious lifestyle issues. This is the cohort of patients who can be described as requiring extensive care.

Extensive care
Extensive care is a fundamentally different way of delivering care for patients with some of the most complex healthcare needs. The aim is to support these patients with proactive, coordinated care, which provides a single point of access to reduce the need for unplanned hospital admissions.
To be eligible for the service, patients must be over 60 years of age with two or more of the following long-term conditions:

  • Heart problems such as coronary artery disease, atrial fibrillation or congestive heart failure.
  • Respiratory problems, such as chronic obstructive pulmonary disease (COPD) or bronchitis.
  • Diabetes.
  • Dementia.

Patients are referred to the service by their GP and an initial multidisciplinary assessment is then carried out with the patient. Once a patient joins the service, lead responsibility for the coordination of their care is transferred to the extensive care team from their GP practice (this is similar to the way in which care is provided when a patient is admitted to hospital).
With the support of their dedicated wellbeing support worker, patients are encouraged to set a number of goals and aims that they will work towards. These form part of a comprehensive care plan that is developed in conjunction with the patient and carer to meet all of their health, wellbeing and social care needs. It also outlines the triggers that define when a patient’s condition has worsened, and the action to take to support and stabilise them. The aim is to encourage the patient to self-manage their own condition and lifestyle wherever possible with the ultimate aim being to help patients reach a point where they no longer need the intensive support of the service.
Two extensive care services, Lytham and St Annes and Blackpool North went live in June 2015. A further four sites are planned to be established in 2016 to complete the roll out of the service across the Fylde Coast.

Enhanced primary care
If the population is considered in ‘tiers of need’ – with those in the extensive care tier being at the top – then the next cohort might compose of people with long-term conditions, which are not well managed or who have mental health, anxiety, drug/alcohol dependence or other social care issues that impact on their daily living. This results in demand on a range of services, which in turn increases pressure on the system, both in terms of capacity and increased cost. This is the cohort of the population described as requiring enhanced primary care.
The aim is to provide primary care at scale by integrating all community services and primary care teams. Our GP practices have been grouped into 10 geographical neighbourhoods, four in Fylde and Wyre and six in Blackpool, representing the two CCG footprints.
In these neighbourhood-registered populations patients will have a single point of access for all out of hospital care needs. As patients’ needs increase, they will access more of the co-ordinated services available within their neighbourhoods and have an appropriate care plan developed to meet their needs. If their condition improves and their needs are more episodic in nature the service input will be reduced appropriately by their GP and neighbourhood team.
The CCGs have been working with a number of key community services to share our vision for new models of care across the Fylde Coast, both directly and through our wider engagement work. The CCGs have indicated to providers of community mental health, social care and voluntary services that in future we will want services to be delivered with a neighbourhood focus. Where opportunities have arisen, some services have already aligned their provision to a neighbourhood focus and additional community nursing allocated across neighbourhoods has laid the foundations.
Implementation started in April 2016 and will finish by April 2017. An initial tranche of additional community health staffing has allowed the new model to be adopted at the start of April 2016, initially focusing on the patients identified by the phased expansion of our risk stratification tool.
During the first year, fully integrated neighbourhood care teams will be established – combining health and social care provision. This will focus on health and wellbeing and support those with physical and mental ill health needs to ensure that parity of esteem is reflected in provision. The introduction of extensive care will enable GP capacity to be freed up so that they are available to better manage and support more complex patients, assuring adherence with best practice to improve health outcomes.
By April 2017 we expect that a further tranche of staff with key clinical skills will allow the full model to operate. At this point enhanced primary care will be a universal service available to all patients who require an enhanced level of clinical care, irrespective of condition.

Dr Tony Naughton, GP and clinical chief officer at NHS Fylde and Wyre CCG on behalf of the Fylde Coast Vanguard.

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