The team bringing wellness back to a community at the edge

The Chief Pharmaceutical Officer Keith Ridge reflects on his visit to Team Fleetwood and what it tells us about multi-professional working:

Fleetwood on a sunny day in April. A big sky, Morecambe Bay glistening as far as the eye can see, mountains in the distance. Royalty used to catch steamers to Scotland from here. Fishing was big, but the town and its dockside are quiet today.

But something new is happening in Fleetwood. It’s called hope.

Health workers and local people are bringing life and a spirit of collaboration back to the town.

On the day we visit, they’re showing the BBC around the Healthier Fleetwood part of the initiative which involves the NHS, schools, libraries, local businesses and more; introducing the team of local people running the Men’s Shed, who are tackling suicide, the Fleetwood Young Chef of the Year, which involves teaching 10-year-olds how to cook, the Harmony in Health singing group, and the community allotment where they’re growing veg for the food bank.

The room is filled with positivity and pride; a ‘can do’ attitude to improving health, that is being led by the community.

Pioneer and founder Dr Mark Spencer, a GP at the Mount View Practice, explains how Team Fleetwood – as they have called the primary care network – has three inter-connected aims:

  • Improving the health of people with complex illness.
  • Managing the ‘wellness’ of everyone through the Healthier Fleetwood initiative.
  • Keeping staff well and motivated.

At the monthly Connect meetings where new ideas for Healthier Fleetwood are discussed by everyone involved, professionals no longer try to propose solutions, or new services, or find funding. Instead they ask the simple question: how can we help you to do it for yourselves?

And it’s created a community revolution.

As we walk around the town, Mark explains how giving people confidence and control is enabling the GP practices and health professionals involved, working together as Team Fleetwood and with the local people, to turn this deprived community and their own challenges around.

Hundreds of local people are involved, including those from the areas where hard to reach groups live; and they are making in-roads in reducing social isolation and providing support. The library hosts over 30 groups who meet regularly, offering free space, tea and coffee. We meet people who were previously obese and who have lost weight, we hear of parents who are learning to cook healthy food with their children, and of the Anon art group which is carefully situated by the drug and alcohol team’s premises so that people needing help and support to overcome addictions find it easier to join.

The pharmacy team is an integral part of the multi-professional team of over 100 clinicians in Team Fleetwood, led by experienced clinical pharmacist and Primary Care Network (PCN) medicines optimisation lead Chris Roberts and working with clinical pharmacist Nasir Isaji and one of the local independent community pharmacy groups led by superintendent Lisa Cottam.

The community pharmacy has been given access to the GP practice IT systems and they work with the PCN as a team to provide good clinical care for people with complex illness and offer access to Healthier Fleetwood where the website offers a ‘try something new’ option as a way into the social prescribing offer.

Good communication means it is working well and there is an intention to spread this further to include the local hospital pharmacy team in future.

We talk about the scourge of poor mental health with the PCN mental health practitioner and clinical team leader Alison Halliwell. Now leading a team of 5.5 people, she describes the starting point: when 42 per cent of GP consultations involved a mental health issue as the primary presenting component. And 10 years into their work the number of GP consultations involving a mental health issue as the primary presenting component was down to 7 per cent.

Now they are running resilience workshops with people with Chronic obstructive pulmonary disease (COPD) and other long-term health conditions, including chronic pain, to help them live well – teaching them how to recognise anxiety and use mindfulness meditation instead of a pill, offering the Healthier Fleetwood activities as alternative options. The PCN mental health sub-group meets every month and involves the community/specialist mental health teams, pharmacy, the Clinical Commissioning Group (CCG) team, housing, the police, the drug and alcohol team, child and adolescent mental health services (CAMHS), the Job Centre, the Family Centre.

Mark makes the point that being a GP or pharmacist doesn’t have to mean the traditional way of seeing patients. He’s being a GP when he goes to the monthly Connect meetings and when he’s singing with the Harmony in Health group, or asking a top chef to mentor the young chefs at the local school. He isn’t prescribing medicines or referring someone for further treatment, but he is improving health.

And over the last two years A&E attendances have fallen by 24 per cent and hospital admissions by 17 per cent.

When I leave, I can’t help thinking, Fleetwood really is the future we’re aiming for.

Dr Keith Ridge

Dr Keith Ridge is Chief Pharmaceutical Officer at NHS England where he is head of profession for the pharmacy professions and the principal advisor on pharmacy and medicines use.

His role supports the Department of Health, broader Government and Health Education England.

Keith is the Senior Responsible Officer for reducing inappropriate prescribing of antimicrobial in the UK AMR Strategy, and leads on issues such as medicines optimisation, digital medicines, pharmacy educational reform and transforming pharmacy practice in line with the NHS’s Five Year Forward View.

He is a visiting professor at the Imperial College Medical School.