Organisation

North East and North Cumbria Integrated Care System (ICS)

What was the aim/problem?

In the North East and North Cumbria more than 263 thousand people are waiting for planned care and around 30,000 of these are classed as priority 4*. Around 9,000 of these people are from some of the most deprived areas in the country. Priority four patients are a lower clinical priority for surgery but there is a risk that while they wait that their health will deteriorate which can then lead to treatment being postponed and/or worse outcomes after surgery.

People living in these areas are known to have greater co-morbidities such as heart and respiratory disease, diabetes, high blood pressure, mental health issues and dementia. This increases the risk of complications during and after surgery.

Evidence shows that taking simple steps before surgery or treatment to improve fitness, diet and mental health plays a crucial role in helping patients to recover more quickly and reduces the chances of them being re-admitted to hospital. In turn this can help to reduce cancellations and postponements.

While support and advice for patients was already being offered to patients before their operation, with some great examples of best practice, the North East and North Cumbria ICB recognised that there wasn’t a consistent regional approach, and it wasn’t targeted towards the people who need support the most. Working as an integrated care system enabled this shift in approach.

Local evidence also showed that going for surgery offers a teachable moment for patients to engage in behaviour and lifestyle changes to improve their health.

What was the solution?

Working with colleagues across the NHS, local councils and the voluntary, community and social enterprise sector (VCSE) the Waiting Well programme was developed. 

Patients are now taking simple steps before surgery or treatment to improve fitness, diet and mental health helping them to recover more quickly and reduce their chances of being re-admitted to hospital. At the same time social prescribing enables health professionals to refer people to a range of non-clinical activities that can improve overall health and wellbeing such as gardening, healthy eating advice and exercise classes. Based on patient feedback, they also now receive support with non-related health issues such as financial and housing advice.

It’s a model of support for some of the most clinical and socially vulnerable patients, using a population health management approach that identifies and segments patient groups by clinical and social vulnerability and gives ensures targeted prioritised support to these people while they are waiting for treatment.

The programme targets patients categorised as needing ‘priority four’ surgery who are from deprived communities and have the greatest need, such as people with learning disabilities, those with uncontrolled diabetes, obesity, and smokers (as a starting point). 

GP practices use RAIDR, a population health management digital dashboard which merges elective surgery waiting list and primary care data to help identify risk factors at GP practice level and patients who may need support while waiting for surgery, empowering them to self-care so that they are ‘waiting well’.

Dr James Prentis, Consultant Anaesthetist, Newcastle Upon Tyne Hospitals NHS Foundation Trust, said, ‘We’ve never had so much detail and information in one place, which allows us to target patients and offer help and support. The data is particularly important when supporting patients with a learning disability who are on a waiting list, which is a group we know are much more likely to live in areas classed as being in the 20% most deprived in the country’.

What were the challenges?

The ICS is the largest in the country covering a population of 3.2 million, with a budget of £7bn and 80 thousand NHS staff. It has some of the highest levels of deprivation in the country, a situation which has been exacerbated by the cost-of-living crisis, which is having the biggest impact on those living in the most deprived communities.

What were the results?

In April 2023:

• 568 patients were contacted and offered support (35% increase from March)
• 203 patients accepted an offer of support
• 195 or 96% of those patients who accepted an offer were from the target cohort in deciles 1 or 2
• 48 patients completed an intervention (increased from 20 in March – numbers are low due to being in the early phase of rollout)
• 28 of those patients were from deciles 1 or 2

Other benefits are better outcomes after surgery, quicker recovery, fewer re-admissions to hospital, reduced cancellations and adoption of longer-term lifestyle changes and benefits.

” I would choose to stay at home rather than socialising with friends and although I know that socialising would be good for me, I could not bring myself to leave the house. Since being asked to take part in this incentive I have left the house three times a week even if it’s to the gym and back, and I look forward to doing my exercise classes.” Waiting Well patient.

What were the learning points?

Initially, the waiting well programme had a medically driven focus. However, learning from patients who have been through the programme so far showed that they required support with non-related health issues too, such as financial worries and housing. The people with the skills to support patients best with these issues are wider than just the NHS and include others, such as VCSE sector.

Next steps and sustainability?

Dr Neil O’Brien, Executive Medical Director for the North East and North Cumbria Integrated Care Board said, “The journey to date has been overwhelmingly positive for everyone involved and most importantly our patients. The collaboration has exceeded our expectations and we are confident that the outcomes from this work will bring benefits for our patients, not just in terms of their outcomes after surgery, but for their longer-term health too. The next phase will be to ask patients who have gone through the programme for feedback so that we continue to learn and evolve”.

Want to know more?

Please contact england.stcomms@nhs.net