Promoting Self Care at The Symphony Programme, South

Case study summary

South Somerset, in common with many parts of the South West, were faced with combined problems of soaring demand for healthcare and rising costs, at the same time as a staffing crisis in general practice and other parts of the system. The model adopted focuses on supporting people to understand and manage their own conditions, link into the voluntary sector locally and navigate the healthcare system through a team-based approach where different professional groups operate at the top of their licence.

 

South Somerset, in common with many parts of the South West, faced combined problems of soaring demand for healthcare and rising costs, at the same time as a staffing crisis in general practice and other parts of the system.

The Symphony Programme was set up in response, through a collaboration between the South Somerset GP Federation (19 practices), Yeovil District Hospital, Somerset Partnership NHS Foundation Trust and Somerset County Council.   It is led by a programme board, which is chaired by a GP and includes four elected representatives from primary care (three GPs and a practice manager partner) as well as the GP Associate Medical Director of Yeovil Hospital, who is also a local GP.  Yeovil Hospital has four representatives including the chief executive, and there are also representatives from Somerset Partnership, Adult Social Care, the voluntary sector and Somerset Clinical Commissioning Group (CCG).

Objectives

The integrated care model had several objectives:

  • Improving support for patients and their families with long term conditions
  • Developing a sustainable staffing model and way of working in primary care
  • Improving the working lives of staff
  • Shifting resources from expensive acute care to primary care and prevention through avoiding admissions and other secondary care activity
  • Enabling a long term sustainable financial model for the health economy as a whole

Solution

The model created had three tiers:

Tier One: Complex care for the small number of patients with the most complex conditions

Tier Two: Service to support patients who need the full resources of the complex care team.  This sees patients managed within primary care but with support from the complex care team

Tier three: Enhanced primary care which supports practices to take a much more preventative and proactive approach to their patient list by expanding the practice team and introducing health coaches

All three tiers are focused on supporting people to understand and manage their own conditions, link into the voluntary sector locally and navigate the healthcare system through a team-based approach where different professional groups operate at the top of their licence.

The Symphony programme team are also piloting MSK (musculoskeletal) practitioners seeing patients in practices without seeing a GP first, diabetes virtual clinics, and hot respiratory clinics where practices can obtain an urgent opinion from a specialist nurse without attending an outpatient appointment.

GPs now work in a team with their health coaches and other staff members, who meet daily or several times a week in “huddles” where the whole practice team discusses the patients they are most concerned about, agrees what actions are needed and who will do what.  The team is also able to put together information about patients which can enable them to spot problems early on.

The health coaches work with patients to help them to develop confidence to manage their health conditions, as well as ensuring that any liaison with other services is effective and coordinated.  Patients can contact the health coaches directly, and often will see a health coach, or another member of the team instead of a GP, freeing up the GPs to focus on the most complex patients.

Three complex care teams are now in place to support the most complex tier one patients.  The teams include key workers, who are the main liaison point and support patients and their families through the care planning process, as well as carrying out some health coaching and ensuring families are linked into other sources of support.  Care coordinators (nurses) are responsible for developing a single person-centred care plan, and providing clinical input, and the team is led by specialist extensivist doctors – GPs or consultants who are focussed on managing complex multi-morbidity.

One of the teams is based in Yeovil Hospital, which has allowed relationships to be developed with the secondary care consultants, meaning that advice can be accessed without an outpatient appointment, and the team lead the discharge planning when patients need to be admitted, reducing length of stay. The new East Team, which is co-located with Somerset Partnership community teams, is working with the practices in that area to develop the new tier two service.  This sees care coordinators attending practice huddles and supporting the staff in practices with care planning, training and advice.  Specialist opinion can be easily accessed when needed and the complex care team can take patients onto their caseload for short periods when required.  This will allow the complex care team to become embedded in primary care and create a wider team.

Outcomes

The care model has been developed by working groups led by GPs on the programme board, and has evolved considerably over time.  It has taken some time to establish the complex care team as practices had concerns about governance, communication, impact on practice finances and about “handing over” some of their patients.  Through joint working, and in particular the introduction of the health coaches in practices and expanding the practice teams, these concerns have been addressed, and the new tier two being developed in the east will enable complex care to become fully embedded in primary care.  GP leadership combined with the resources of secondary care has been crucial along with a willingness to reflect on feedback and adapt the models over time, and this process will continue. The programme team are very happy to share our experiences and learning along this journey.

The programme is now fully developing the tier two service and expanding this to the rest of south Somerset.

Tips for adoption

Engagement of primary care at every stage of conception and design.

Strong clinical leadership from primary care – The Symphony Programme Board has four elected representatives of primary care and a further GP who was Yeovil Hospital’s Associate Medical Director.  The workstreams are led by primary care.

For more information please contact

Lisa Pyrke
Communications and Engagement Manager
Symphony Integrated Healthcare

Mobile: 07500 977168
Website: www.symphonyintegratedhealthcare.com
Twitter: @SymphonyProj