Dee Kyne explains how investing in a service redesign secured savings for one practice and health improvements for its patients.

Three years ago Pathfinder Healthcare Developments Community Interest Company  set out to redesign the services delivered at and through Smethwick Medical Centre in Sandwell, a GP practice with a population of 10,000 in the heart of the West Midlands.

The focus of this work was to become more patient friendly, provide accessible, efficient services and to improve the working day of the clinician. Smethwick Medical Centre’s partners recognised it was time to make changes so working practices became more efficient. This would enable the practice to be ready to meet the changing world and new contracts head on.

A key component of this was a community of committed clinicians led by Dr Niti Pall. The outcomes of this work were significant: delivering savings on hospital use, a risk stratified patient population and some replicable, impactful interventions.

Pathfinder Healthcare Developments was set up and is owned by Smethwick Medical Centre. It was formed to enable the partners to move the risk of redesign away from normal day to day delivery, thereby not jeopardising “bread and butter” work. It raised the money and managed the change.

The area of Smethwick has significant social and economic disadvantages. With large numbers of people from diverse ethnic backgrounds, high unemployment and major health issues, it would be easy to be daunted – but Smethwick Medical Centre has shown that real change is possible at practice level.

Over the past three years we risk stratified our patient population, redesigned care and managed our patients’ health to focus on providing services designed around the people who use and work within them. The service redesign was evaluated with the help of independent evaluators who surveyed and interviewed patients, talked to staff and stakeholders, observed our services, assessed patient records, and monitored costs and primary and secondary care use over time. That evaluation included feedback from more than 1,500 people.

Programme goals and measurable outcomes

The programme set out to deliver the vision of outstanding excellence in long term conditions management using a population health approach in three years.


  • Accessing “hard to reach” communities
  • Enhancing self-care and awareness of own health needs
  • Developing innovative ways of accessing services

Measurable outcomes

  • Reduced secondary care use
  • Impact of self-managed care
  • Improved patient experience (access streamlined care, self-empowerment)
  • Proactive screening
  • Value for money

Overall improvements

Of the people attending events aimed at raising awareness, 97 per cent said they found them useful and informative, 97 per cent would like to attend similar events in future and 100 per cent said they might make some changes to how they care for their health as a result. It is difficult to measure whether the events affected people’s health but looking at the records of a random sample of participants we found that 77 per cent had improved blood pressure six months after attending an event. People also lost weight, stopped smoking and attended health education courses.

We put a database on our website to signpost people to local health and social care services. Over a one year testing period there were 32,449 visits to the website and about 200 people used it each month.

We developed a triage “callback” service so people ringing to book a same day appointment are now offered a call back within two hours by a GP or nurse practitioner. The aim was to reduce unnecessary face to face appointments and ensure people can get help quickly. When asked what they would have done if the callback service was not available, 41 per cent of people said they would have attended accident and emergency – so callbacks have reduced the use of hospital services.

We also set up a telephone support service run by nurses from Aetna UK Health Services. In total, 256 people with long term conditions at risk of hospitalisation received intensive care management and a behavioural change programme. The aim was to help people learn about their role in keeping themselves well, when to contact health professionals for support and how to exercise, eat healthily and take their medicines correctly. After the programme, eight out of 10 people said they knew more about their health condition and the same number thought the calls showed them how to keep themselves well.

In total, 84 per cent of people said they were more confident about looking after themselves, 59 per cent said they started eating differently because of the calls and a similar proportion said they did more exercise (65 per cent). The cost of admissions increased by just 11 per cent for those enrolled compared with 55 per cent for those not enrolled.

Group consultations are offered to help people learn more about their long term conditions. This has been refined over the past two years and we now run drop-in group medical appointments for non-specified long term conditions.

Pathfinder Healthcare Developments, working with Sandwell Primary Care Trust and Aetna UK, invested £500,000 into the venture. This money enabled us to design, test and refine interventions that could be replicated elsewhere, thereby costing other localities considerably less to implement. We are rolling this programme out to 55,000 patients in Sandwell.

Over the past three years we have seen major improvements in access to services and the quality of care. There are also trends towards improved health outcomes, reduced use of hospital services and reduced costs. We are already seeing positive trends such as improvements in blood pressure before and six months after attending community healthreach events and improvements in blood pressure and body mass index before and after attending group consultations. People taking part in telephone care management also said they were more likely to eat healthily and exercise. Some said they had lost weight, stopped smoking and started walking regularly as a result of receiving telephone support.

Trends in A&E visits and unplanned admissions are improving in the practice at a faster rate than other practices. This may also improve costs. In the year ending March 2011, the practice had an overspend of about £600,000; in the year ending March 2012, an underspend of about £300,000 is predicted.

How to make your care programme a success

Care management programmes are cost effective and relatively easy to implement. The key to effective care management is the need to have it driven through the local GP so there is a significant uptake of the service by the patient population. This generally runs at 30 per cent but we created a 70 per cent uptake by owning the care management programme and the GPs encouraging patients from the practice end.

Group consultations may sound daunting but we made a lot of mistakes from which others can learn and we can now share our work and the implementation process. We have developed training materials and programmes for replication.

Turning triage into an access service is common sense and has to have a “locality flavour”, paying attention to local feedback from local people to underpin effective design.

Volunteer programmes take some energy but many of those in localities across the country are run by associated organisations and can be used within GP practices effectively – there is no need to reinvent the wheel.