Partnership working. Building partnerships with acute hospitals, voluntary and community services. Featuring examples from Birmingham and Coventry. Anne Forletta, My Healthcare Birmingham; Katherine Hewitt, Gateway Family Services, Birmingham.

1. Healthy Futures
Ann Forletta - SDS MyHealthcare
Katherine Hewitt – Gateway Family Services
General Practice Transformation Champions
7th March 2017

2. 2
SDS MyHealthcare
How we began
23
GP Practices
Serving
123,000
Patients across
South & Central
Birmingham

3. 3
Initial funding of £2.4million
from the Prime Minister’s GP
Access Fund for a 12 month
Wave 2 pilot – to improve
access to General Practice and
stimulate innovative ways of
providing primary care service
£2.4m
Matched funding and
support from Birmingham
South Central CCG
Working in collaboration with
South Doc Services Ltd, a GP
co-operative that has been
providing primary, community
and secondary care services
since 1996
SDS MyHealthcare
How we began

4. 4
SDS MyHealthcare
Partner Agencies Include:

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Our Vision
To deliver high quality, accessible
access to primary care at scale

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Our Vision
How we achieved it
• Increasing capacity, access and choice
• Maximise use of new digital technologies
• Manage Primary Care Demand by ensuring
that patients are seen by the most appropriate
member of the extended healthcare team
• Expansion of Workforce skills

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Manage Primary Care Demand by
ensuring that patients are seen by
the most appropriate member of the
wider healthcare team

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Problem
Recognition that many patients repeatedly
consult their GP for non clinical reasons
Practices don’t always have the knowledge to
sign post patients into the most appropriate
service or the capacity to support patients in
navigating the health & social care system

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Problem
Would establishing a Care Navigation service
ensure that this group of patients could be
managed more cost effectively?
Would it free up clinical resources
Would it ensure that patients with complex
social care issues received the level of
support needed

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Gateway’s Objectives – Two Primary Outcomes
GP/Practice Staff
(Primary Care)
To free up their time by taking on
the support of patients who present
with issues that are of a social
rather than medical nature.
Patients
To be able to manage their social
needs independently or if this is not
realistic to be able to manage more
effectively with support from more
appropriate sources.

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Measurement
GP Impact
Assessment of how many times the
patients saw the GP in the
preceding 6 months and the 6
months following support.
Patient Impact
Risk map showing reduction in risks
attached and self reported.

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Background
• Specialism in outreach and supporting
people with vulnerabilities
• The concept was one we had been
considering for some time and discussions
had taken place with some key GP’s
• The latest in a range of Para Professional
support roles
• 12 month pilot (Nov 15 – Oct 16)
• Funded via Prime Ministers Challenge Fund
• 23 Practices with which we had an existing
relationship
• The Manager and Coordinator both
experienced in delivering similar services plus
¾ of Navigators knew our way of working

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The
Process
Referral into
service only via
GP/Practice Staff
Step 1 > Step 2 > Step 3 >
Patients contacted
within 48 hours and
further assessment
carried out over the
phone to further clarify
issues and suitability
1st Appointment or
visit set

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Risk and Protective
Factors model
(aligned with
national frameworks
including the ageing
well element of the
life course)
Step 5 > Step 6 > Step 7
Support focused on
eliminating/reducing
risks using behaviour
change techniques
Tailored support
provided, flexible in
terms of time & style
Step 4 >
Support Worker
(Navigator)
allocated and
records opened on
database

15. Risks – Gathered from 150 Patients
15
Risks from 140 Patients
Personal
Circumstances
Domestic Abuse
Housing
Vulnerable Adult
Financial Hardship
Social Isolation
Caring Responsibility
Environment
138
Behavioural Factors
• Alcohol
• Substance
• Smoking
• Physical Activity
• Requires help with daily life
• Poor management of LTC
• Poor mobility and balance
• Lack of skills / access to IT
119
Status
• Weight
• Mental Health:
- Low reported wellbeing
- Stress and anxiety
- Diagnosed condition
• Frail
106

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Outcomes for GPs
Assessment of 24 patients shows that there were 50
less appointments in the period following support, a
25% reduction
“GPs are happy with the service because it is
reducing the burden of social needs patients on
primary care”
“The use of non-clinical staff members instead of
GPs is cheaper by around one third”
Healthy Future Care Navigation deep dive draft report.
General Practice Access Fund Evaluation, Mott Macdonald

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Outcomes for Patients
“ Feedback from patients via an app (IAA), indicates
that self resilience levels have increased due to the
scheme”
“Anecdotally there is evidence of behaviour change:
the scheme has helped some patients to understand
that the GP is not always the most appropriate source
of support for helping with non-clinical issues”
Healthy Future Care Navigation deep dive draft report.
General Practice Access Fund Evaluation, Mott Macdonald

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Evaluation Group
Received full support
Limited support provided
Declined due to suitability
Referred onto more appropriate support
At end of Sept 140 closed files
67 accepted the service and
received support

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Outcome of Evaluation Group
Of the 35 who received the full
support package
Risks reduced
Partially reduced
No change

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Impact Assessment

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Learning
Age - Expected over 65
78% under
Low complexity due to isolation,
bereavement, frailty
High complexity due to significant mental
health, isolation/independence, alcohol and
frequent combinations
Volunteers to be used widely in step up step
down approach
Use of Volunteers largely felt unsuitable
Vulnerable +
There is a gap - more intensive and
complex than vulnerable but not being so
vulnerable that they meet Adult Social
Care definition of vulnerable

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Meet Brandon
• Vulnerable adult
• Learning disability
• Unsuitable accommodation
• Financial hardship
• Social isolation
• Low reported wellbeing

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Top Tips
• Clear definition of Care Navigation and what needs to be achieved
• Service provider needs to have a detailed knowledge of health & social services
plus third sector services available locally
• Relationship building with General Practices
• Staff need to be suitably trained to be prepared for work with complex patients
• Staff need ongoing support to be able to meet the demands of the role

24. Questions?
For further information contact
SDS MyHealthcare: a.forletta@nhs.net
Gateway Family Services: katherine.Hewitt@gatewayfs.org