How to develop new care models

From his very earliest days as chief executive of Yeovil District Hospital Foundation Trust, Paul Mears was thinking ahead. “When I first got to the trust, one of the conversations I had with the then-chairman was what are we going to do in the future, because clearly the model we’ve got now isn’t going to suit us going forward. We’re going to have to do something very, very different.”

Be the change

It is a conversation which many other leaders of smaller hospitals will have had, and one which inevitably leads to consideration of new care delivery models. The next question is how to make such a change a reality, and it was this which was on the agenda for an exclusive HSJ/McKinsey summit held last month.

Mr Mears told delegates Yeovil’s journey began with a close examination of precisely what was happening in the local care economy. “We pulled together all the data from primary care, community services, social care, acute hospital care, to really try and understand the costs being incurred across the system.”

What this study showed was that just four per cent of the local population were consuming 50 per cent of the health and social care resources.

Cue the introduction of the South Somerset Symphony Project, which is now one of the primary and acute care systems (PACS) vanguards. The project has involved the creation of new care hubs, specifically designed to support the four per cent of patients with the most complex needs.

Every practice bar two in Somerset has a vacancy for a GP

They are staffed by extensivist doctors – previously GPs, they now care exclusively for this group of patients – and also have care coordinators to help develop a single plan for a patient’s health and wellbeing.

The initial results are highly promising. “We’ve had a cohort of about 200 patients and that patient population has seen a 33 per cent reduction in their admissions to hospital compared to the previous year,” Mr Mears reported.

“If they do get admitted, there’s about a 50 per cent reduction in length of stay when they are in hospital. So it’s starting to have benefit – we’re in no way there yet, there’s a long way to go, but it’s starting to bear fruit.”

It is not just about a transformation of acute care, Mr Mears emphasised.

“When we were doing the work on complex care, we realised – like everybody – that not just the hospital is struggling; primary care is really, really struggling. Everybody says to me it must be easy to recruit in places like Somerset, because everybody wants to go and work in a nice place. That probably was true a few years ago, but it’s not now – every practice bar two in Somerset has a vacancy for a GP.”

The workforce issue

Forbes Watson can relate to that experience. He is the chair of Dorset Clinical Commissioning Group, another healthcare organisation which covers a pleasant part of the south west but which has seen its attraction to potential staff wane.

“Workforce is a significant issue for us now,” Dr Watson told summit delegates. “Historically, Dorset’s been a popular place to come and work, particularly for GPs. That really is no longer the case: many of our practices are really struggling to recruit new and younger GPs, and we are seeing a number of retirements.”

Every day there’s a huddle of GPs, nurses, practice manager, receptionist, and allied health professionals and they talk about who they are worried about

The hope is a system-wide review, with the aim of implementing a new integrated model of care, may bolster the area’s appeal to professionals. “We’re focusing on care closer to home and prevention, starting in people’s home, then moving to GP practices and primary care, then to community hubs with or without beds, and finally to acute hospital.”

He continued: “A lot of the narrative has been about what’s happening in the acutes, but of course the majority of care is delivered in the community. So we have been looking very much at our community offer and our primary care offer.”

It is a similar story in Yeovil. Redesigning primary care is a central plank of the vanguard project, with 13 out of 19 GP practices now running an enhanced care model. “It’s very much a systematised way of running a practice – really looking at how you can get control of the demand that’s coming through,” Mr Mears explained.

“So every day there’s a huddle of GPs, nurses, practice manager, receptionist, and allied health professionals and they talk about who they are worried about. And often it’s the receptionist who says: ‘Mrs Smith used to come down on Tuesday to get her prescription and hasn’t come for the past couple of weeks,’ so then it’s: right, let’s pick up the phone and find out what’s going on. GPs are already starting to tell us it’s having a big impact on the way they care for patients, and patients like it because they’re getting a much more personalised service.”

Health coaching

Health coaching has also been introduced. “So there are staff who work with the GPs and nurses and who are the primary point of contact for patients who, predominantly, will have one or two long term conditions. They give lifestyle advice, support on making changes to diet, speak about medicines adherence, link with voluntary sector groups – all the things people would otherwise see the GP about.”

We recognise that if we don’t have sustainable primary care locally, that’s going to have a big impact on the hospital as well

Mr Mears told delegates engagement with primary care had been absolutely critical to the Symphony project. “It’s been a big challenge, and I know for lots of people primary care is that difficult nut to crack in terms of integration, so we’ve worked really hard to get primary care on board.”

It seems such efforts have been successful. A primary care operating company has been created within the area which, while run by GPs, is actually a subsidiary of the hospital.

“It currently has three practices, and we’ve got another seven that are due to join over the next six months. That really is our attempt to look at how we can bring primary care together to work at scale, and get consultant physicians out into primary care – working with their GP colleagues to make sure wherever possible care, particularly for those with long term conditions, is being managed outside the four walls of our hospital.”

It feels like the sort of new model Mr Mears told colleagues was needed when he started his role four years ago. “We recognise that if we don’t have sustainable primary care locally, that’s going to have a big impact on the hospital as well,” he concluded.