New Models of Care – The Symphony Programme

Case study summary

The Symphony Programme was set up in response to high demand for healthcare, rising costs and a GP recruitment crisis.

 

South Somerset, in common with many parts of the South West, faced linked 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 to this as a collaboration between 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 CCG.

Together they have analysed the population, joined up data, developed new integrated care models and new organisational forms to support primary care.

The new integrated care model   focusses on supporting people to understand and manage their own conditions, to 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 license.

Health coaches are now in place in 13 practices, with a further three about to be launched.  By then 52 health coaches will be in place – a significant boost to practices.  The Symphony programme is also piloting Musculoskeletal (MSK) practitioners seeing patients in practices without seeing a GP first.

In addition, diabetes virtual clinics are being trialled, where a consultant from the hospital discusses the most complex diabetes cases with a practice team in a virtual format.  This enables changes to be made to medication and management to better manage patients’ conditions, without the need for a hospital appointment.  Hot respiratory clinics have also been designed, where practices can obtain an urgent opinion from a specialist nurse without attending an outpatient appointment.  The next priorities are pharmacy support and mental health support workers.

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, agree what actions are needed and who will do what.  The team is also able to put together detailed information about patients, which can enable them to spot problems early on.

The health coaches work with patients to help them develop confidence to manage their conditions, as well as ensuring that any liaison with other services is effective and coordinated.  Patients can contact the health coaches directly and will often 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.

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. GP leadership combined with the resources of secondary care have been crucial along with a willingness to reflect on feedback and adapt the models over time, and this process will continue.  We are very happy to share our experiences and learning along this journey.

Tips for adoption

  • Engagement of primary care at every stage of conception and design.
  • Strong clinical leadership from primary care – the 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.

Symphony have lots of experience and documentation and would be willing to share.

For more information please contact

Lisa Pyrke
Communications and Engagement Manager
Symphony Integrated Healthcare

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