The National Association of Primary Care (NAPC) podcast is now live with its first episode, which will focus on the Frontiers programmme. Discussions will explore the context/background of the programme (reinforcing the fact that work has been underway for some time), the programme’s main aims and why these are important to NAPC and the health and care system, what makes it different (focusing particularly on the programme’s role in amplifying the voices of those who historically haven’t had a platform to speak about transformation etc (e.g. acute specialist clinicians) and the value this brings, and the role of NAPC in developing the approach.
To ground the discussion, colleagues from Hampshire will talk about how they have used the approach (and NAPC’s support) to initiate transformational change, setting up their group and identifying areas of focus – which include health creation, service transformation (making services more person-centric, multidisciplinary and integrated), using data and intelligence, resourcing population health and embracing digital and innovation.
Listen to the NAPC 'Hampshire - Rebels with a Cause' prodcast episode here!
Rebels with a Cause
A quiet revolution is taking place across the health provider landscape in Hampshire, where health professionals are joining forces with other local services to build resilience in their neighbourhoods, redress inequalities and rebuild capacity in the workforce and communities.
The Hampshire New Frontiers Group is the first of three -projects set up by NHS Providers and the National Association of Primary Care (NAPC) to improve the way primary and secondary care work together for the benefit of patients and communities.
Unlike most efforts to reorganise health care provision, this one didn’t start with a grand vision and a comprehensive strategy underpinned by bureaucracy and implemented by managers but with small-scale projects designed by clinicians, working with and for their local populations.
‘We have been working on projects where we see benefits for patients and residents’, says Shirlene Oh, Chief Strategy and Population Health Officer for Hampshire Hospitals NHS Foundation Trust. ‘We are person-centric rather than service centric and that enables us to take risks because we are getting people’s feedback on what works and what doesn’t’.
Targeting unmet need
One such initiative is the use of data searches to identify the most intense service users – typically people with unmet needs who regularly attend accident and emergency departments.
These people can then be reviewed holistically by the virtual health hub team. A tailored package of support can be coordinated and delivered by the most appropriate person to support their unmet need. That maybe via a frailty nurse consultant, a social prescriber or even citizens advice.
In time, they hope to understand themes emerging from these intense service users so ‘gaps in the system’ can be plugged and support provided earlier to effect changes in the population rather in just the individual.
David Cruttenden-Wood, a general and colorectal surgeon, who is Clinical Director for Virtual Healthcare at the Trust, and a member of the New Frontiers team explains: ‘‘We are not catering for these groups of people very well. We don’t understand what in society has let people down for them to feel that their only way to get help is via A & E’s front door.’
The group has so far worked with GP surgeries and homeless shelters to understand how best to reach out to people identified as needing help and support. They are also actively working with the local prison service to understand this unique group people’s health needs (physical and psycho-social).
The hope being that if these often-chaotic groups of people could be better understood, then their real needs (not our perceived needs) can be provided for. By interlinking and providing enhanced efficient coordinated care the hope would be to prevent them from spiralling into a preventable crisis.
Intelligence about the population is gathered using traditional health data through a population health lens. This allows them to focus on the wider determinants of health within the local population.
An external partner has allowed them to combine this data with ‘earth observation data’ to create new interactive place-based indicators of vulnerability. This includes the impact of cold homes, hot weather, homelessness and threats to mobility and accessibility.
This will help to target resources specifically for groups and neighbourhoods with the greatest needs.
A radical shift in mindset
These kinds of initiatives involve a radical shift in mindset from a top-down, service-led approach to a bottom-up approach focused on people, places and communities. As Shirlene Oh explains: ‘Along the continuum we want to move the mindset from “doing to” to “doing for” to “doing with” and eventually to “done by”. In one of our local wards, we have seen a shift in ownership and autonomy, with the residents themselves starting to run and lead meetings that were originally organised by the NHS. These are the tiny wins that build momentum.’
This philosophy is enthusiastically endorsed by the local authority, Test Valley Borough Council, which hasn’t hesitated to put its money where its mouth is. All local areas receive a share of the £2.6 billion UK Shared Prosperity Fund, introduced as part of the Government’s ‘Levelling Up’ agenda. And Test Valley has allocated a large proportion of its allocation to provide capital funding for a Health Hub based in Andover.
A space in The Chantry shopping centre, used as a vaccination centre during the pandemic, was rebranded earlier this year as Andover Health Hub. Residents can discuss their health concerns and take advantage of a range of health checks to detect early signs of conditions including kidney and heart disease, stroke and dementia.
The new facility will help to ease pressure on overstretched GP practices while contributing to the overall aim of providing NHS services in community settings. NHS and local authority leaders see it as the first step towards providing a fully functioning health hub offering a much wider range of services.
A levelling up success
In terms of levelling up, the new hub can already be counted a success. James Moody, Head of Strategy & Innovation at the Council, reports that in its first four weeks of operation, the hub had completed 450 health checks, 150 of which were on people from deprived communities, who are the prime focus.
Test Valley is also pump priming a local Community Health and Wellbeing Worker (CHWW) programme, which has already been successfully established in Westminster and has sparked interest in several areas of the country.
Recruitment is currently under way for two CHWWs, who are expected to start work in April. These will not be health professionals, just people who like being helpful to their communities, explains Shirlene Oh. They will be assigned to specific neighbourhoods where there are known health inequalities and will visit all the households on a regular basis to proactively identify any new illness or problems, providing support with the help of local authority and health services.
An evidence-based initiative
This ‘low-agency intervention’ is an evidence-based initiative based on a model from Brazil, which has the largest primary care system in the world. ‘We are constantly scouting for evidence-based solutions and policies that support our work’, says Shirlene. ‘This is about meeting people where they are, in their homes, and it is a universal offer, not targeted based on clinical conditions.’
‘These workers will become trusted members of the community and therefore people will be happy to open up to them. Because they visit regularly, they will be able to check whether or not services have been taken up.’
Breaking down traditional siloes
The overall focus of the New Frontiers programme is on population health improvement. But whereas such initiatives are usually led by and focused on primary care, the Hampshire project has involved colleagues from secondary and mental health care in bid to break down siloed working.
‘Surprisingly all of us agree on the basic tenets’, says NAPC Clinical Director, Dr Nav Chana. ‘It’s not about primary care versus secondary care or physical versus mental health and all the sector rivalries that people talk about but building on the expertise we all bring to deliver some of the solutions that we need.’
Rebel ideas
Part of the inspiration for New Frontiers came from high performance expert Matthew Syed’s best-selling book Rebel ideas: the power of diverse thinking. Says NAPC Faculty Member Andy Mullins: ‘If you have people with different perspectives, by getting them together you can get more insights. If you invest a small amount of time into allowing people to be creative it is extraordinary what can be achieved. It might be small, but it grows.’
The focus on creativity is not limited to health professionals. The New Frontiers group is also keen to free up the creativity in local communities by adopting an Asset Based Community Development (ABCD) approach. This focuses on building on the talents and enthusiasm of natural community leaders to help people lead healthier lives.
‘We are used to providing things and, in so doing, disempowering communities’, says Shirlene Oh. ‘Instead we need to change our thinking so that we help existing assets to flourish. We are working with people who are already local leaders – such as those running mother and toddler groups or clothes exchanges – to shine a light on what they do and work with them to see what they can do to improve the health of their communities.’
The initiative started in 2020 with the main aim of developing a community-centred approach to improve wellbeing in areas with the worst health outcomes.
A new Community Builder post has been created to move the work forward, and a range of activities, including coffee mornings, school holiday events and educational food programmes are now in train or being planned.
Virtual solutions
Virtual healthcare is a major theme in Hampshire, accelerated, as everywhere, by the constraints of the Covid pandemic.
Virtual ward programmes aimed at preventing hospital admission and facilitating early discharge have proliferated across England. In North and Mid Hampshire, the Virtual Healthcare Hub has brought together a diverse range of health professionals from all sectors to create ‘a hospital without walls’.
The hub allows people who would otherwise need admission to hospital to be supported and monitored in their own homes or care homes, with step-up care available if necessary. It also enables people in hospital to be discharged early into a supportive environment.
The virtual ward programme is expanding rapidly across all conditions and specialities. They have proven it to be safe, liked and trusted by both patients and clinicians in the region. As confidence grows, they hope to see a paradigm shift in the population towards the acceptance and demand for virtual healthcare.
Importantly, they have not been limiting themselves to the tight funded boundaries of ‘virtual wards’. They acknowledge early supported discharges are important but they also recognise there is so much more that can be done to support the regions health using hybrid enhanced virtual and face-to-face care that might not ‘earn the trust money’ but is ‘the right thing to do’ to protect the health and well-being of the population.
Virtual outpatient clinics are a huge hit
Virtual outpatient consultations have proved a huge hit in Hampshire, as elsewhere, with ‘staggeringly positive’ feedback from patients.
‘In colorectal surgery we thought patients would hate the idea of virtual consultations’, says David Cruttenden-Wood. ‘But we find they enjoy it, they can speak on the telephone freely and they can be very honest.
‘Even the most traditional physicians have noticed that this new way of working is acceptable: it’s safe, it’s enjoyed by patients, it’s cheap and even the naysayers realise that it is quicker and easier.’
A new sense of purpose for health workers
Far from imposing additional strain on health professionals exhausted by a combination of Covid, the resultant backlog, normal winter pressures and a depleted workforce, the New Frontiers initiative has had an energising effect.
‘People are at capacity and burned out’, says David Cruttenden-Wood. ‘They need new ways of working and collaborating.
‘The NHS is cash poor but energy rich and we have been able to work with the idea that people aren’t necessarily stuck working on a ward anymore. In our two Foundation Trusts we have started blending our workforces, taking people who might consider jumping ship and giving them a diversity in their jobs they haven’t had before.’
‘This new way of working across the patch, across all localities, gives people real purpose. We can’t give them loads of cash, but we can give people purpose and a real sense of value.’
An infectious energy
The energy generated by the range of projects and activities in Hampshire is infectious, and NAPC leaders are keen to spread the word. Says Andy Mullins: ‘Every time we left Hampshire Dr Nav Chana and I felt energised. We are looking forward to working with colleagues in Hampshire to take their ideas to other systems and bring some of this joy to their lives.’
The last word should go to James Moody of Test Valley Borough Council. Referring to the gratifyingly high use of the Andover Health Hub, particularly by people from deprived communities, he says: ‘That’s a step in, it builds momentum, it builds interest, and you can build on that.’
‘So let’s not write a big strategy for the next 10 years that we haven’t got a chance of delivering. Let’s think about what’s important, let’s iterate, let’s learn together, let’s take little wins, and slowly but surely that’s how you keep the energy in the system wide conversation.’
