Rachna Vyas is deputy chief executive and chief operating officer for Leicester, Leicestershire and Rutland ICB. Her 20-year NHS career has included posts at CCGs and an acute trust. As the health and care system has developed, so has Rachna’s portfolio into a whole system transformation across all sectors in Leicester, Leicestershire and Rutland. She tells Healthcare Leader editor Victoria Vaughan how primary care fits into the transformation, including the development of neighbourhood teams.
Victoria Vaughan (VV): What’s happening with the shift from secondary care to primary care and neighbourhood teams in Leicester, Leicestershire and Rutland (LLR)?
Rachna Vyas (RV): We’ve got a rich history through the Better Care Fund of primary care, local authorities and community trusts working together. For quite a while, we’ve had a complex care specification in place and we’ve seen that, where we’ve brought people together in a multidisciplinary way at neighbourhood level, there are better outcomes.
An example is Leicester City where we work out the right outcome from a neighbourhood perspective. There are three components: how do we find vulnerable people; how do we make sure we’ve wrapped all health and care services around those patients; and how do we make sure that, when they’re in crisis, we’ve got a service that picks them up?
We have a risk stratification tool – the adjusted clinical group system that we bought from the Bloomberg School of Public Health – and, with our practices, that helps identify the most vulnerable population from a disease burden perspective.
We then call in those patients for a longer appointment – 20 minutes – with the GP for a care planning type conversation. They look at what’s wrong from a multi-morbidity perspective, not a single disease perspective, and if they need further support from local authority or the VCSE sector, then our care navigators pick that up. We run our care navigator service with our PCNs and they put in place all of the things needed so that the person is as safe and stable as possible.
VV: So, you identify the vulnerable and you’re proactive about preventative measures. And what’s the service if they go into crisis despite that?
RV: We’ve got the integrated crisis response service, which is a local authority service that works in partnership with the community trust, and they will pick those people up.
Services work together to go into the patient, figure out what was wrong, and put other things in place to help – such as grab rails or safety tech. As a result, we’ve got an 80% non-conveyance rate for falls at the moment, which is one of the highest in the country.
We’re trying to use the ethos of ‘it doesn’t matter what your badge says, you’re here to keep that person safe,’ and it’s worked really well from an outcome perspective.
We’ve got similar outcomes for palliative care patients. We’ve got one of the lowest bed days for over-75s in the region and the country because we operate the same model for when patients are getting much frailer towards the end of their life.
So far, we’ve picked up between two and five per cent of the total population and we want to build on that and do it at scale. To achieve it, we recognise that we’ll have to move resources around – and I don’t mean resources in terms of just money. I mean people and the way we work.
VV: How will you do it at scale and how do you plan to move the resources for that to happen?
RV: We’ve got a lot of people going into the acute trust for short lengths of stay and then straight back out again. So, our focus is to limit that.
As an example, we’ve got LUCID, which is a programme for chronic kidney disease management. We had some really long bed waits for that cohort and, of course, worse outcomes, which means dialysis. That’s not good for the patient and it’s also very costly.
So, we’ve taken the specialist resource we’ve got in secondary care and put it in primary care and we’re seeing an immediate impact. People’s outcomes are changing because we’ve got that multi-disciplinary approach in that we have a very specialist resource talking to primary care who understand risk and multi-morbidity in a different way.
We’re confident that in five years’ time, most of that service will be run in primary care, not secondary care. And if we can do that for one pathway, why would we not do that for all of our long-term conditions?
Cardiovascular disease and the family of diseases around it is where we’re going to go [next] and then the second biggest problem we face is respiratory. Those are our two biggies. We’ve now got a series of workshops focused on how we are going to apply that same ethos to those two areas.
It’s really exciting, actually. This is a cultural shift, not just a financial shift. All of the interface issues that we would normally see across primary and secondary care just disappear because they’re working as a team.
VV: The mechanics of getting staff out of an acute trust and into the community can be difficult. How did you approach those conversations? Was there one thing that won people over?
RV: We did a proof of concept and did it in a phased approach. We started with a small cohort of patients and got some really clear evidence that we were able to keep those patients safe in the community and out of the acute trust. And it just built from that.
There was a clinical belief that we are doing something different here, which was going to have a real benefit to the service and to the patient outcome. I didn’t do any presentations of these business cases – our clinicians were doing all of that and in a solid evidence-based way. And it was a joint approach – a GP and a secondary care clinician or a pharmacist from secondary care and one from primary care. The whole point was, ‘We are not here for our organisations. We are here for this pathway’.
What tipped it for us was that the data was robust, it was clinically led and we had some early evidence.
It has really energised everybody because it’s the first time we’ve been able to show that we can do this.
VV: Have you made any changes to primary care delivery? And are there any shortages in your primary care workforce?
RV: We have a huge focus on GPs. We’ve got a workforce transformation programme – the fellowship programme – to help us get more people in.
A lot of the younger GPs are telling us that they don’t want to be a GP for five days – they want to do a joint role with specialisms – so we’re working with our acute trust on how we make that happen. We have one of the country’s biggest teaching hospitals on our doorstep and we’re working in partnership with them to deliver some of those roles.
In terms of delivery, we’ve tried to make it easier for practices by standardising things. We came from three CCGs into one ICB, and those three CCGs had different prices for different things they were doing, not doing or commissioning.
So, over the past two years, we’ve had a programme of standardising that with support from our LMC, our GP place leads and our clinical directors. Now, we’ve got what we call a ‘basket of services’ in which we’ve agreed some specifics about what a practice will do and what the payment will be, and we’re building on that. If something comes up that isn’t currently commissioned, the discussion is how to get it into the basket of services and what we’re going to do collectively to agree the payment.
VV: What about ARRS staff? How do you think about them when looking at shifting care and resources?
RV: Our biggest successes have been the social prescribers and the care navigators. They’ve really helped to bridge that gap across general practice and the wider system.
We’ve been really flexible with our practices – as much as we can be within the rules – about how they use those roles. But the social prescribers in each PCN may be doing different things and I’ve also got local area coordinators in local authorities.
So, we need an assessment of what each role is doing – or is not doing – and then think about how we link them into the wider system to get the absolute best for that pound.
There is a community health and wellbeing plan for each neighbourhood, and within that is their strategy of how we bring those roles together or how we use them in a better way. It’s about looking at everybody working for the health and wellbeing of that population, bringing them together, reducing the duplication, and figuring out what we’re going to do.
VV: Do you envisage it looking slightly different from one neighbourhood to another? And is that the same for the health focus?
RV: We’ve basically said that we will come together as teams of people around natural neighbourhoods. That means that our PCNs are working across two or three teams or the teams are working across two or three PCNs. We’ve accepted that’s how we get the best for our populations.
We’ve got two layers in each neighbourhood – a strategic team that works on the strategy and an operational team, which comes together to figure out what they’re going to do to better the health of that population. It is working really well for us.
My district areas and cities are broken up into various places and each has a neighbourhood plan, which is our joint integrated plan as well as the priority for that area because each neighbourhood has different needs. Each neighbourhood has five priorities that they’ve picked. We haven’t mandated anything; they’ve picked the priorities from their data. And where three or four neighbourhoods are working on the same things, we’ve said: ‘Actually, let’s not do this on a neighbourhood level, let’s do it at place or system’.
VV: What about health inequalities? How are you approaching that?
RV: We’ve given our allocation for health inequalities directly back to the PCNs and practices. I know quite a few places across the country have chosen not to do that, but we were very clear that the only way we’ll ever shift the dial – particularly on the work that we talked about from a prevention perspective – is to make sure that money is protected.
We have been quite specific with our PCNs about what we would like in return. There are equity plans, PCN by PCN, and they’re working out exactly where they are now from a baseline perspective and where they’re going to get to. There’s a big focus on cancer screening, vaccination and mental health because those are the three areas where we see the biggest gap between one area and another.
VV: Finally, where would you like to be in five years? And how will you know if your work has been a success?
RV: Really, it’s making sure we’ve got neighbourhood models of care that cater to the needs of the population and recognising that every one of those might have to be slightly different for that population. That, for me, would be a measure of success because it moves us forward.
