It is acknowledged that healthcare services in the UK need to adapt, focusing attention on prevention and improved provision of care closer to home. Benefits of integration throughout the NHS and between health and social care is not a new concept and can lead to better outcomes [1, 2], and numerous exemplars exist [2].
The relationship between social factors and health is well documented [3,4,5] highlighting the impact of social isolation, loneliness and socio-economic status on healthcare use and patient outcomes. Arguably, traditional mechanism of social care provision has led to variation in services provision, making integration with healthcare more difficult [6]. However, there is growing interest in ‘social prescribing’, linking people to community and voluntary sector support and services to address non-medical needs. Indeed, a recent scoping review identified 159 social prescribing programmes across a number of countries across Europe, North America and Oceania alone [7]. In England, a number of initiatives such as the NHS Long Term Plan [8] and Proactive Care Guidance [9] set out to improve the approach to coordinated multi-professional care. Following a 2018 Parliamentary Review [10] to identify key challenges facing health and social care, the Welsh Government also set out plans to revolutionise care delivery in Wales [11], aiming to bring health and social care together, with a National Transformation Programme to facilitate change. This initiative included targeted funding to support new models of partnership between health, social care and third sector (e.g. non-profit organisations, charities, voluntary and community groups). One project which won early support from this fund was “An Accelerated Cluster Model” led by the Cardiff South West Primary Care Cluster (CSWPCC).
In Wales, primary care clusters include groups of neighbouring general practices which work together to deliver health and care services. There are currently 60 primary care clusters in Wales [12]. These vary in their provision and deliver different services dependent on the local need. While their aim is to bring together services involved in health and care to promote wellbeing of individuals and communities [11], traditionally there has been little or no integration between health, third sector, and social care services.
Aim
This project aimed to reduce emergency admissions for patients registered with practices in the CSWPCC focusing on developing multi-disciplinary working, and an emphasis on improved connections between patients and communities, and across services. Mechanisms included enhanced delivery and provision of social prescribing initiatives, a focus on prevention by identifying people who are at risk and actively supporting them to remain as independent as possible (e.g. by reducing unscheduled admissions and readmissions), improved interagency working (i.e. between health, social care, and the third sector), and improved advance care planning.
The scope of the new service provision was based on the Frome Compassionate Communities model [13]. Its goals were:
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Implement asset-based community development at cluster level.
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Developing workforce well-being.
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Identifying at risk individuals and actively supporting them to remain as independent as possible.
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Ensure personal needs are prioritised through individual care plans.
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Establish a multidisciplinary team (MDT) to support vulnerable individuals.
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Establish a cluster discharge liaison hub.
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Develop a cluster model to maximise opportunities for seamless working and allocating resource based on population needs.
These focus on the implementation of four key elements: a strong community MDT meeting regularly; an integrated care hub supporting patients on discharge from hospital; community development and social prescribing; and advance care planning.
This paper aims to describe the implementation and roll out of the programme, and provide feedback on the available outcomes.
Design and setting
The CSWPCC was established in 2014, with a core membership of 11 GP Practices serving an ethnically diverse population of approximately 74,000 people. There are high levels of deprivation within the cluster and over 45% of the population live in the 20% most deprived areas of Wales [14]. Additionally, 2016–2018 data suggests people living in the South West Cardiff cluster area are more likely to smoke and less likely to be a healthy weight than the general population in Wales [15]. One of nine GP Clusters within Cardiff & Vale University Health Board (CAVUHB) area (which provides healthcare services to over 470,000 people in the Cardiff and the Vale of Glamorgan), it had one of the highest hospital admission rates within the area at 32% above the average.
The CSWPCC were keen to implement lessons from previous schemes [16], particularly from the Frome “Compassionate Communities” project [13]. The Frome model focused on person centred care, social prescribing, development of community assets, and enhanced patient review following hospital discharge, and led to a reduction in hospital admissions of 14% [13].
Funding
Transformation Fund grant funding of £1,287,463 was awarded to this project early in 2019.
Methods
Multidisciplinary team (MDT) setup
Historically, within the South West Cluster, organisations were working in silos with little or no interaction. In February 2019, leads within the cluster implemented biweekly MDT meetings, aiming to identify support for patients with complex or social needs, bringing together GPs, cluster pharmacists and staff from agencies including the local council, CAVUHB, community services, mental health teams and third sector groups. With documented patient consent, GP’s would bring cases to meetings for discussion and an opportunity for teams to offer support. There were no strict referral criteria, or limit on the number of available slots, and any MDT member was able to refer patients. The purpose of the MDTs was to bring different individuals and groups with a wide range of skills together, allowing the cluster to provide patients with medical and non-medical solutions to their problems. Integrated IT systems were made accessible to partner groups allowing information to be shared between key stakeholders with formal information governance arrangements, and standard operating procedures around this. Over time the attendance at these meetings expanded with representatives from groups detailed in Table 1.
As well as providing advice and support on complex health issues, groups provide practical support with home adaptations, improvements and repairs, meal provision, medication reviews and prescription collection. They also give advice on housing, benefits and debts, managing energy and food costs, grant opportunities, substance misuse, wellbeing, and opportunities to connect with community and social groups. Transformation funding allowed GP time to be backfilled allowing them to attend the MDT’s. Other roles were already funded but time was prioritised for staff to attend. Meetings moved online in March 2020 in response to the COVID-19 pandemic.
Discharge liaison/well-being hub
A discharge liaison hub was established in September 2019, with dedicated staff equivalent to two full-time administrators and a co-ordinator financed by the transformation fund. The Hub also hosted a dedicated worker from Independent Living Services (ILS), and occupational therapist and pharmacists, enhancing access. The initial aim of the Hub was to identify and contact potentially vulnerable patients following hospital discharge. These individuals were telephoned within 48 h of discharge allowing them time to settle back home and identify unmet needs. Hub staff were then able to offer appropriate support from the stakeholders attending the MDT meetings. This gave patients access to support to live independently, e.g. by installing ramps and hand rails, or accessing ‘meals on wheels’. Cluster pharmacists provided standardised medicines reconciliation of patient discharge summaries allowing medication issues to be identified and resolved promptly. This marked a significant change from the standard of care where this work was carried out ad hoc by practices, usually by the duty GP actioning medication changes, and no wellbeing call to the patient after discharge.
COVID-19 saw the focus of the Hub extend to provide emotional support and linking patients with community groups offering services including prescription collection and food shopping.
Community wellbeing connectors
Wellbeing Connectors were newly commissioned from existing social prescribing partners, to improve capacity and develop capability to self-care. Unlike similar models, team members were employed by community organisations, not directly by CAVUHB. Staff were able to identify and fill gaps in wellbeing resources, activities and services in the local area. They have been able to work across the cluster supporting patients to develop and maintain community links and improve their own and one another’s lives. As well as being a contact for isolated and vulnerable patients, connectors offer people a range of services to improve well-being including bereavement peer support, coffee mornings, women’s only exercise classes, men’s group, and gardening club. Some offer support to particular groups such as those who speak English as a second language. Patients were also supported with digital inclusion to help them feel more connected.
Advance care planning (ACP)
Living with a chronic or life limiting illness can lead to uncertainty, and there are challenges in ensuring patients’ wishes are accommodated when these are not well defined. Having open, honest conversations about what is important to an individual and what they want in the future and documenting this clearly, can help make sure these wishes are met. To support ACP within the cluster, extensive training was undertaken, including practice and care home staff, and recording processes were formalised via a template embedded within the clinical system. Information on ACP was included in the Cluster newsletter which is available to all patients and engagement events were held across the cluster including in two local Mosques. A Macmillan community development worker was separately funded at this time and supported this area of work, being regularly available in practice waiting rooms and providing direct support for those patients on palliative care registers. This provided interconnections within existing services, including hospice at home, and linking in with the cluster practices to reduce silo working and improve communications. ACPs allow patients to record their wishes on future care including preferred place of care, and place of death and ensures they are shared with loved ones and healthcare professionals.
Data collection
Key outcomes were collected using mixed methods. Quantitative data was collected on the number of patients contacted by staff at the Hub, and the wellbeing team, the number discussed at MDT meetings, and the number of GP visits pre- and post-discussion at MDT. Other data collected included: number of medicines reconciliations, referrals to mental health services and other organisations, and the number of signposting suggestions. The rate of GP referrals to secondary care assessment units was available throughout the project with statistical process control charts to monitor trends as per standard Quality Improvement methods [17]. Assessment units are the first point of entry for patients referred to hospital as an acute medical/surgical emergency by their GP. Hospital bed days was collected continuously throughout the time period by a third party provider, Lightfoot Solutions UK Ltd., separately commissioned by CAVUHB.
Feedback was also collected from service users accessing the MDT, and those interacting with the Wellbeing connectors via the Short Warwick-Edinburgh Mental Wellbeing Scale (SWEMWBS), which measures mental wellbeing in the general population. In-depth qualitative interviews conducted by an independent researcher (KW) were undertaken with 27 staff, including representatives from the cluster, the council and third sector. These involved GP’s, pharmacists, occupational therapists, project support and admin staff, and operational managers. Participants provided informed consent including consent to publication of findings. Topic guides were developed to guide these interviews and are available in the supplementary material. Data were analysed thematically analysed using NVivo.
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