Organisation develops initiatives to deliver integrated services within the community and empower resident, reducing A&E attendances and acute hospital admissions

Outline:

Fleetwood is a socially disadvantaged community with a population of just under 30,000 residents, with significantly health inequalities and traditionally poor health outcomes.

The prevalence rates for all major long term conditions are significantly above the national average, but especially mental health issues such as depression and anxiety as well as those long term conditions associated with smoking, obesity, drug and alcohol misuse.

In 2014 the 3 GP practices in the town faced a severe GP recruitment and retention crisis with only 8 GPs remaining from what would normally be at least 16 GPs across the town.

There was a genuine risk of collapse of General Practice. In the subsequent 4 years not only has that situation been completely turned around with the long term sustainability of GP practices now ensured but there has also been significant integration across all Primary Care Services within the NAPC Primary Care Home community of practice, as well as genuine resident empowerment and a vibrant social prescribing pathway via Healthier Fleetwood.

The outcomes have been full recruitment of GP and all other health care professional posts, life changing resident stories and a significant reduction in A&E attendances and acute hospital admissions.

Challenges:

First, there was a desire to better integrate services across all the Primary Care Providers in the town. This not only included the 3 GP Practices but also community nursing and therapy services, community pharmacy, local dental practices, the specialist mental health provider, the community drug and alcohol provider and the Acute Hospital Trust.

It quickly became apparent that the biggest challenge and the key to successful integration was to do with building relationships, getting to know each other as human beings and building trust. This has been a constant focus over the past 4 years.

The “what” and the “how” then became very straightforward. The second solution was to look at our residents as a large part of the solution, rather than patients being part of the problem.

Healthier Fleetwood began almost 3 years which has empowered residents to take control of their own lives, their own streets and their own community. The main focus of Healthier Fleetwood is to listen to what really matters to residents and then for residents to become the “doers” rather than the “done to”. We’re also addressing childhood obesity by teaching our children how to cook through the Fleetwood Young Chef programme.

Outcomes:

Working with the Children and Families Division of Blackpool Teaching Hospitals we have focused on the 20 families in the town whose children are at highest risk of hospital admission.

This integrated approach has received excellent feedback from the families involved and has also significantly reduced the need for hospital services, especially A&E. We have also integrated Mental Health Services across Primary and Secondary Care as well developing an integrated, Primary Care based service for patients with liver disease due to Hepatitis B/C and/or alcohol-related cirrhosis.

We have also developed to COPD pathway to be delivered through community pharmacy, having opened up full read/write access to EMIS web for community pharmacists.

The most significant change though has come about through Healthier Fleetwood, with residents genuinely taking control. Residents have designed and implemented their own social prescribing pathway with over 24 different activities now being available, many off them resident-led. This has genuinely changed residents lives. Attendance at A&E has fallen sharply with a 7% reduction in 2016-17, followed by a further 16.7% reduction in 2017-18. Acute hospital admissions have also fallen by 6.5%, this against a backdrop of increasing hospital activity levels across the remainder of the CCG.

Spread:

Fleetwood has been used as a model for the development of Primary Care Networks (PCNs) nationally by NHS England and locally through our STP. There has been a 100% take up of the PCN model by Practices across Lancashire and Cumbria STP.

The Fleetwood case study has been shared during NHS England national conferences and through webex events. Fleetwood is also being put forward as a centre of excellence for integrated care by the National Association of Primary Care, having won their Primary Care Home of the Year in 2018.

We have hosted numerous visits to the town by people keen to learn from our experiences and a lot of information is available on the Healthier Fleetwood web site. Our residents are central to the roll out and sharing of good practice with them being present and participating at all events.

Value:

Our 2 main desired aims were the survival of General Practice in the town and also the empowering of residents to take control of their own lives and their own health. We believe that we have achieved both aims. We now have fully integrated care across the town with a leadership group that has over 30 members from across all organisations and including residents.

Our governance structure and way of working has been replicated across PCNs in our STP and nationally. Residents are telling their own stories about how their lives have been transformed. We are now again at a full compliment of GPs in the town, with other GPs and nurses actively seeking work opportunities in the town.

We have also increased skill mixing within General Practice with new clinical roles such a practice based paramedics, clinical pharmacists and primary care mental health workers increasing the resilience and sustainability of our GP practices, also with access to acute and routine GP appointments available 7 days per week. Although a reduction in secondary care activity was not a stated desired outcome for us, it is naturally a very welcome side- effect of working in this way.

Involvement:

There are over 50 partner organisations involved with Healthier Fleetwood. A full list can be found at: www.healthierfleetwood.co.uk/contact/partners The NHS providers and partner organisations that are involved within the Fleetwood Primary Care Home model are detailed in the section below: Monthly resident connect meetings are held in the town, led and organised by the residents themselves, with representatives of provider organisations present to listen to what matters to residents and to work with them to co-produce desired changes.

The main focus of these events is wellness and resident empowerment. There are bi-monthly Fleetwood leadership meetings where all partner organisations come together with residents to look at how illness, both acute and long term, are managed.

There is a Healthier Fleetwood Website and active use of social media through FaceBook and Twitter. The residents are now in the process of turning Healthier Fleetwood into a Charitable Incorporated Organisation. There is a risk/gain share arrangement in place between Fleetwood Primary Care Home and the CCG where a proportion of identified underspends on specific schemes can be re-invested locally.

Fleetwood Primary Care Home is now in detailed discussion with the local authority, Lancashire County Council to integrated their local services such as well being services, social care, housing and schools into a “Total Neighbourhood” model.