Lost and lonely

In South Warwickshire a programme has been created to help the over 75s combat loneliness in order to live a more independent and happy life

NHS South Warwickshire Clinical Commissioning Group (SWCCG) is currently facing a number of challenges that are undoubtedly impacting other groups nationwide, but most prominently a rapidly growing and ageing population. As with the rest of the UK, the population across Warwickshire is growing at an unprecedented rate and between now and 2021 we’re expecting almost a 10% increase in over 75s and subsequently need around 720 additional dwellings per annum.¹
We are currently facing significant and increasing healthcare challenges, particularly in the over 75s, with dementia being one of our biggest concerns. People are living longer than before, and more and more people over 75 are living with long-term medical conditions that require regular and specialist care and monitoring. As a result there are many unplanned hospital admissions for those who are frail or have complex physical and/or mental health and care needs. In addition, almost 30% of emergency admissions and emergency readmissions are for people aged 75 plus. It’s widely acknowledged that focusing attention on patients that are lonely, isolated or frail delivers quantifiable and improved quality of life, medical outcomes and general wellbeing.

Strategy
Having identified the ageing population as one of our biggest concerns, we recognised the need to commission services that are not only flexible and responsive to the diversity and changing needs of our population, but that are cost-effective in an increasingly challenging financial environment. Our main aim was to tackle the issues impacting the ageing population and help improve the quality of life for those living with long-term conditions. This would primarily be by changing the way we provide care for these patients, and enhancing their experience of local services, as well as ensuring its consistency across the area.
The model was based on the precise needs of our patient population, providing support for individuals to enable them to look after their own health and wellbeing, while improving access to services closer to home. This was backed up by smaller-scale, specialist hospital services.
The main principles of our approach were:
Increase life expectancy, tackling specific health conditions for certain age groups.
Improve the quality of life for people with multiple long-term conditions by changing the way we provide care to these patients and ensuring consistency.
Reduce the amount of time people unnecessarily spend in hospital by putting care plans in place to support patients with certain health conditions.
Give more people a positive experience of hospital care and care outside of hospital by improving patient experience.
Links to Better Together (part of the Better Care Fund) – which supports the broader aim of increasing independence and ensuring people are better equipped to manage in their own homes and to reduce emergency admissions by 2.3%.
Each principle would have specific
and measurable targets in place to monitor its success.

The project
With the population of 75s and over at just under 26,000 in March 2014, SWCCG allocated £1.3 million for 2014/2015 on a recurrent basis, and it was agreed that the CCG would:
Produce an information booklet initially known as the Silver Book.
Provide an online resource to support clinicians.
Commission a generic service – a proactive care team.
Practices then fed back to advise they would prefer the CCG to allow them to commission services they felt were appropriate for their local population, in essence opting out of the generic service. This was agreed on the basis that a clear distinction was drawn between any new service and the services/funding already in place.

Process
In early September 2014 the CCG issued a template for GP practices to bid for funding, and complete either individually or collectively. This was supported by Q&A sessions at Members’ Councils. The template covered an overview of the service, its delivery model, outcomes, patient engagement, equality and diversity, financial model, health inequalities, how this differed from existing schemes, activity monitoring, implementation plan, risks and mitigation plans.
Early October marked the closing date for applications.
At the end of October applications were assessed and scored by representatives from the CCG (officers not clinicians) Wawrick County Council, public health and the local medical committees, with lay members of public and patient involvement.
Early January 2015 Prime GP was selected as a chosen service provider and scheme commenced.

Overview of service provider
Prime GP is a comprehensive healthcare consultancy and project management service that aims to address the increasing financial and health pressures placed on the NHS. The organisation’s Prime of Life: 75+ Project is dedicated to helping to deliver proactive services to improve socialisation and isolation; reduce patient dependence on GPs in the ageing population; and increase patient self-care and physical and mental wellbeing.

Implementation
The project is initially being piloted by four practices across South Warwickshire, and was easily implemented within eight weeks of it being awarded due to the development of a clear service level agreement that outlined roles, responsibilities, reporting and expectations across all practices and the voluntary sector. In addition, a guidance document including all templates and protocols for implementation, monitoring and evaluation was produced to support the practices involved. The model was executed efficiently and effectively worked with the practices, ensuring little disruption and maximum impact.

What it involved?
The service aims to identify over 75s who are lonely or socially-isolated and recommends the level of support they require. Utilising the experience of healthcare professionals and those from the business arena, the service is run on a day-to-day basis by an over 75s coordinator who works alongside the four local practices in Warwickshire.
The needs and support of each patient inevitably varies, so the coordinator works alongside each individual to get to know them on a one-to-one basis – to find out their interests, hobbies and likes and dislikes. They then use this information to identify the health or social care intervention best suited to them. Older patients are put in touch with voluntary organisations, charities and community services and encouraged to engage in activities or services that they may benefit from.

Outcomes
The project has proved successful so far, not only achieving financial savings month-on-month in comparison to the previous year, but it also helped reduce unplanned and avoidable hospital admissions and reduced GP appointments. In addition, it has been well received by the patients, who have praised the help and support they’ve received, which has empowered them to live a more independent and happy life. The success of the project is measured by monitoring the impact it has had on the individual it’s working with, using primary and secondary care data and also noting significant reductions in the number of elderly people visiting their GP, and subsequently A&E admissions, as a result. Since its launch, the project has supported more than 175 patients, with 34% of the over 75s population across the four practices informed and aware of it. Results to date have shown a 22% reduction in GP appointments and up to a 20% reduction in A&E and unplanned admissions (based on monthly data).
Prime 75+ has not only helped tackle current issues. The team has found that they have been able to identify some personal or social issues that don’t initially have a direct impact on GP visits or hospital attendance, but left untreated could escalate and result in a potential crises for the individual, increasing demand and pressure on health and social care providers.

Sue Phillips, head of strategy and joint commissioning at NHS South Warwickshire CCG.

Reference
1 Coventry and Warwickshire Clinical Commissioning Groups. Transformational Change: Transforming Lives. Published 2014