Andy Brooks
Welcome to the Transforming Primary Care podcast. I’m Andy Brooks, the chair for today’s discussion. I’m a GP and the clinical chair for the National Association of Primary Care.
In this episode, we’re discussing work that is currently underway across the eight pioneer sites in the North East and Yorkshire region, taking part in the National Neighbourhood Health Implementation Programme or NNHIP. The neighbourhood model aims to fundamentally change the current approach of a reactive NHS with multiple separate services, which is often a confusing place to navigate for the public, towards one which is proactive, actively seeking vulnerable people who are at risk of increasing health and care needs before things escalate. The model also looks beyond healthcare, encompassing the wider social determinants of health and the interplay between the NHS, the voluntary, community and social enterprise sector, local authorities and beyond.
Wave 1 of the programme is backed by £10 million and began in September 2025, with the ambition to scale up more services over the course of next year. This first wave covers 43 sites across England, from Cornwall and the Isles of Scilly in the South-West to Sunderland in the North-East, ensuring neighbourhoods nationwide can benefit from these new changes.
Today we will discuss the incredible work underway in this region to deliver better care for our local populations. How is a joined-up neighbourhood approach already helping to deliver the 10-year plan commitments around prevention, digital and offering more care closer to our patients’ homes. Who better to be part of the panel today than our four guests? Thank you very much for joining in.
We’ve got Sarah Everest-Ford, a local improvement coach for the National Neighbourhood Health Implementation Programme in North-East Lincolnshire, Dr. Lucy Falcus, GP and Medical Director for Hartlepool and Stockton Health GP Federation. She provides clinical leadership to Stockton NNHIP programme.
Also joined by Dr. Richard Carr, a GP at Modality AWC and clinical lead within the Bradford and Craven NNHIP area in West Yorkshire. He also contributes to the programme in Surrey in his capacity as transformation lead.
And then finally Dr. Simon Langmead, who is also a GP and clinical lead for the NNHIP programme in Rotherham in South Yorkshire.
What a great panel. I’m sure we’re going to have good discussions over the next few minutes, thinking about neighbourhood health. I was wondering if I can put the first question.
When this programme started, what were you asked to focus on as part of that work and perhaps a little bit of how things have evolved so far?
Sarah Everest
Thanks Andy. So, the overarching ask was to focus on adults with long-term conditions and rising risk. What we didn’t want to do in North-East Lincs was focus on a specific disease area. So, we identified our cohort of people that we’ve been working with using the ICB population health management tool and we defined our cohort, as people who had to have two or more long term conditions – moderate to severe and the multimorbidity segmentation, five or more A&E attendances in the year. Then we separated out our age categories.
We were looking broadly at the kind of 60 plus, but the demographics of one of our or two of our GP practices, Open Door and Quayside, it made more sense to lower that age range. So, we went from 30 plus. Then we’ve been having regular huddles going through this cohort of individuals. And I think what’s been really good and positive is the engagement and the role the voluntary sector has played in the work that we’ve been doing in North East Lincs. They’ve sort of really started with that kind of what matters to me conversation with the individual. So, trying to look at kind of those wider needs of a person, not automatically going to that, focusing on the medical side which has been working really well. I think it has highlighted a few things. We’ve got some really lonely people that aren’t necessarily getting the support that they need, but equally we’ve got people that have got lots of different services going into them that aren’t necessarily coordinated as best they could be some really complex social lives and some really vulnerable individuals. And I think what’s really interesting when we bring all the partners together in the regular huddle that we’ve been having is the kind of different professional perspectives when we’re talking about the same individual and what they might have experienced and their understanding of what that person needs. I suppose, versus kind of what the individual wants and needs as well. So yeah, it’s been an interesting start, small steps, long way to go, but yeah, I think we’ve been doing okay.
Andy Brooks
Thanks, Sarah. So, all sorts of things you mentioned there. I’m sure we’ll pick up on a few of those things there. Interesting that you chose not for specific disease, but people with long term conditions and also interesting about the age there, about extending some of the age. Thanks, Sarah. Richard, be great to hear your thoughts.
Richard Carr
Great, thank you. So similar to Sarah, really, in our area, the focus was less about a specific condition and a more recognition of increasing age and multiple long-term conditions and multi-morbidity and really trying to, you know, encourage that leftward shift in terms of proactively identifying cohorts using population health management strategies and tools. A specific programme that I’ve been leading more recently has been in piloting the e-Falls risk stratification tool, which has been rolled out in our area for the last five or six months. It’s been developed by the same people who developed eFI, which is a stable part of all primary care systems. And it’s really looking to assess people’s risk of falling over the next 12 months by giving a percentage score and using that risk stratification score, we’ve been able to pull groups of patients into different cohorts that have allowed us to tailor our intervention accordingly.
So those at higher risk have had a more medical approach through a holistic assessment, including healthcare assistants, GPs, other primary care colleagues to really look at medication reviews, advanced care planning, what could we be doing more to support that person in their own home? And yeah, that more holistic assessment that takes quite a bit of time from a medical perspective. The more intermediate cohort who maybe don’t benefit as much from that holistic assessment, we’ve been targeting more with remote monitoring through the acute trust, which I can touch upon later, has been an interesting part of the programme, but maybe been limited by the type of remote monitoring that we’ve been able to use. And then we’ve also been involving our voluntary sector partners in the community. And really, that’s been an interestingly, extremely impactful part of the programme with some of the lower risk cohort who really benefit from getting out of the house, being encouraged to do exercise programmes in the community, affecting some of that loneliness problem that Sarah touched upon there.
So, it’s been really important and interesting to see the range of interventions that we’ve been able to offer, and the feedback anecdotally has been extremely positive to this point. I think the evidence through a proper data-led evaluation will hopefully back up some of the positive feeling that has been shared by staff and patients alike.
Andy Brooks
Thanks, Richard. So again, lots of rich stuff going on there. Interesting use of data there from your systems and thinking about risk. And then, as you say, cohorting populations. Thanks, Richard. Just, yeah, Lucy.
Lucy Falcus
Hi, so I’m involved in the programme in Stockton-on-Tees and we’ve taken a slightly different approach in finding our cohort of patients. So, like the other two speakers, we’ve looked at a cohort of patients with multiple long-term conditions. We haven’t specified which conditions they should be, but we’ve gone for three or more long term conditions in the same person. And we’ve looked at a cohort of people between the age of 50 and 64. We did that quite intentionally. We could have looked at an older cohort which have a higher chance of landing up using urgent and emergency care services.
But one of the things we wanted to try and look at was a person as part of their whole family. So, starting neighbourhood literally within that unit and people in our area, in the most deprived part of our area, between the ages of 50 and 64, possibly still have parents, but more importantly, are likely to have children and even grandchildren at that age. And if we can do something to improve their health where they are at, we are really wanting those health benefits to filter down to the younger generations.
For example, if we can help keep someone in work, we know that will improve their own situation and it provides example is more like that their children and grandchildren will be able to or want to be in work. So, we have looked at sort of case finding from a range of areas. So, we’ve used computer-based tools, but we’ve also worked with the people that come to our multidisciplinary huddle, and we’ve said you probably know some of these people in our cohort already. So can you bring cases as well. And something quite open the case finding because we’re probably all working with similar patients, just not knowing that each organisation is working with the same people. So, we’re just trying to tie it all together a bit more.
Andy Brooks
Thanks. Thanks, Lucy. Interesting, the difference with the cohort you’ve chosen. I really like that concept around the family and the extended family. That’s really interesting to hear about that. Simon, be good to hear from yourself.
Simon Langmead
Yeah, just to keep the trend going, we were a bit different again here in Rotherham. And you know, at the start of this process, we had some quite wide-ranging discussions with our system colleagues and our patient representatives and things. And we had so many areas we thought we could work on. And in the end, we decided to work on three different cohorts as part of the pilot and largely looking at what our population health needs were – looking at what good things were happening already that we could build on really. And so, we’ve ended up doing some prevention work, particularly around trying to increase uptake of the over 40s health check for adults. We’ve seen that certain parts of our borough were taking that up quite well and other parts really weren’t. So, we’re doing some targeted intervention on that and thinking about how we follow on from that as well once we’ve completed the health check with offers to people.
We’re doing some rising risk work. Again, we’ve gone for a slightly younger cohort on that. We’re going for kind of 18- to 39-year-olds with a significant long term health condition who’ve also got a mental health concern as well. Seeing particular concerns with that group growing quite a bit and accumulating long term conditions at a younger age and often not managing their physical health very well. So, we’re doing some work on a practice basis for that cohorts through a process we were already doing called proactive care, bringing system partners together to have MDT-type huddles around patients and see how we can best help them. And then yeah, probably similar to some of the earlier comments, we’re also doing some complex frailty work as well.
Again, patients with four or more long term conditions and unplanned attendances at hospital in the last year. Again, trying to engage all parts of the system to do some good wraparound care for those patients. So, similarities and differences and it seems like we’ve gone for a few cohorts as opposed to focusing on one. So interesting to hear what’s been going on in the other places.
Andy Brooks
Yeah, thanks, Simon. There are a few things that struck me. People have been doing different things, but one of the things that’s really common that came through is understanding the needs of the local population. So, it’s not just what the data says, but bringing in the wider community knowledge. I guess one of the things about the neighbourhood programme. It was the second chapter, I think, wasn’t it, in the 10-year plan, neighbourhood? So, it’s clearly front and centre about this concept of neighbourhood, about where people actually live and work and as local as possible. And that’s come through really strongly with some of the comments that you’ve made. At NAPC, we look after or provide the national coaches for 16 of the 43 sites. And what we found is where people have really thought about a local population, really tailored it to what their population needs are, they’ve had some really important success. It’s hard sometimes, isn’t it, for institutions to think about a geography and a population rather than their own organisation, and that’s one of the things that we’ve found as part of the programme. When people do that, you get some of the benefits that you’ve described. Also thinking about your point, Sarah, about loneliness, thinking about making sure it’s not a medical model, but it’s also not a physical health model, it’s a mental health model, but also that social model and all those wider determinants that people have talked about, that seems to be something that’s really important. And also moving away from a national health service that loves to count activity as opposed to think what really matters for people. And some of the comments about – we’ve had some really soft stuff back about people are really getting benefit from this. Obviously, we need to wait for the evaluation. But that strongly came through some of the things you were saying there, which aligns with what we’ve also found. Given the 10-year plan and the three shifts that came, we’ve already had some prevention mentioned by Simon. I think, Richard, you’ve talked about some of the digital and data stuff. But I was also wondering from many of your other things that you’ve been doing, have you got things that illustrate some of the three shifts that the plan talks about. Lucy.
Lucy Falcus
Yeah, it’s amazing that once you start thinking about things with a neighbourhood lense, you can then see many things I do as a GP per day being better through that neighbourhood lense. So, as part of the work with Hartlepool and Stockton Health GP Federation, we already work with our acute trusts on urgent care. We’ve been doing that for a number of years now and we have hospital consultants approaching us as a federation to say, here is a problem, what could we do together? So, as a federation, we’re now looking at this with our neighbourhood lense on and thinking, okay, this patient has a problem. The answer to that problem is probably not a hospital waiting list where they’ll be seen in 12 to 18 months’ time.
What could be done? And the answer is often a lower-level intervention that’s done now and at home and in the community that will mean that patient will not need the hospital services. So, I think that the hospital to community, we can see so much potential in our area and that’s so important in the care being better, being quicker, more accessible, and also really thinking about that prevention. Can we prevent a small problem becoming a big problem by working a different way? And it’s really quite exciting when you start thinking about things in this lens.
Andy Brooks
Yeah, thanks, Lucy. It’s a great example of care close to home is not doing something in hospital and then doing it in a different location. It’s doing it differently or things might not be needed a different way. That’s a great example of that. Thanks, Lucy. Richard, did you have any more thoughts on this topic?
Richard Carr
I just wanted to build upon that. I think historically maybe one of the areas that has become more difficult is that relationship between communities and secondary care. And I think through this programme, there is an opportunity to really strengthen some of those relationships, as Lucy just mentioned. And I think one of the areas that the programme we’ve started to pilot with the e-Falls programme has been around, as I mentioned, some of the remote monitoring aspect and looking through the 10 year plan lens and thinking about how do we incorporate helpful technology to really benefit our patients in the community? And that survey that is being led by our team as a neighbourhood, but also involving the secondary care team – their remote monitoring team – in this pilot programme and really helping to build those professional relationships between us who, to be quite frank, I didn’t know a lot of my colleagues who I’ve been working with on this – a huge part of this is building those professional relationships as well as, you know, making care more joined up for the patients, that will only come with tighter relationships between different organisations, secondary, primary, community, VCSE sector. And I think part of our programme has highlighted to me how that can be strengthened through these types of programmes. So I hope that continues as we move forward.
Andy Brooks
So it sounds like that by having something to do with your consulting colleagues, you’ve been able to build relationships. And also, I don’t know whether this is true, it sounds like you’ve also benefited personally and the sort of skills that you’ve learned as well in terms of how to work with colleagues as well. Would that be fair to say that?
Richard Carr
Yes, absolutely. And I think for me, I’ve seen, as you mentioned in my introduction, I’ve worked in the Surrey system as well and continue to do so. And we’re part of a neighbourhood pilot there. And it’s interesting to see across the country how the difference in context and existing relationships through legacy and history just impacts the whole functioning of a neighbourhood programme from the outset because it’s not like we’ve just developed neighbourhoods from scratch. There’s already an existing system that those are founded upon and some of those relationships in the Surrey system I work in, I would in part say are stronger than the ones I’m working with now. And it’s thinking for me in my role, thinking about how we translate some of that learning and learn from the experiences I have there and transfer it into the work I’m doing in Yorkshire as well. So yeah, absolutely, thinking about how we do things differently with colleagues across different organisations.
Andy Brooks
Thanks, Richard. Sarah, be good to get your thoughts on this.
Sarah Everest
Yeah, and I completely agree with Richard in terms of the importance of relationships and trust between colleagues. Yeah, we found that’s been absolutely essential. But then I also think in the context of neighbourhood health and communities, it’s building the relationship and the trust with communities – we’ve had in the past quite a lot of mistrust. And for us, it’s been developing some co-produced community plans with our areas, our geographical areas that got the greatest need and the highest inequalities and thinking about kind of neighbourhood health through that wider lens and so really, not the medical model. And some of the stuff that’s come out of our neighbourhood plans from conversations with communities is really simple stuff. Well, in theory, simple stuff. So, we’ve got lovely green space, but it’s not being used. So how do we think about that in a different way, not just thinking about how we can get more appointments at the hospital or whatever it may be. And we have a real challenge with the number of people that don’t have access to a car. So, getting to appointments and things is really difficult. So we’ve started to do more stuff going out to where people are and one of my team have been doing some brilliant work on blood pressure checks, going to footy matches, the local YMCA, community centres, and I think really just taking some of kind of the traditional stuff out to where to where people are going to be going. And for me, that’s kind of our opportunity through some of the neighbourhood health work is starting to do things a bit differently.
Andy Brooks
Yeah, thanks Sarah. So, it’s not only about moving care closer to home, but involving the communities in the way their services is delivered and where their service is delivered. And that’s the thing we might come back to actually, but you’ve started as well. Just to come to you, Lucy, and then just want to make sure as well that any other thoughts about the three shifts that you might have. Lucy?
Lucy Falcus
Yeah, it was just a point that Sarah and Richard made about the importance of relationships and relationships in the wider sense of health and social care and voluntary sector. One of the really refreshing things in our area has been that our conversations have not started about money. They’ve started about patients and need and moving sickness to prevention, analogue to digital, hospital to community. We’ve built trusting relationships because we haven’t started from a place of, we’re worried about our own budget and identity. We’ve started from a ‘what together could be done better for this patient closer to home and outside of hospital.’ And that’s been a really key way for us to build the relationships and the trust.
Andy Brooks
Yeah, that’s a really important point. And my experience as well nationally is that there’s either people start with the money and therefore it becomes a very difficult question. And when people start with the money, they start with a tiny little bit of investment as opposed to the entire resources that everybody has got. The other downside potentially is that when people don’t start with the money, they never get to the money. And at some point, we do have to have some of those conversations, so it’s getting that balance right. But good point about the wider aspects as well about it’s not just about health, local authority services and voluntary sector – they often bring a different emphasis, things that we perhaps might come back to that as well. Simon.
Simon Langmead
Yeah, Andy, I think I totally agree with your point. And I think, yeah, it’s relationships and shared goals, isn’t it? I think if you can get everyone agreeing on where you want to be, that’s the first thing that needs to happen, isn’t it? Because if you don’t do that, you don’t get anywhere. And I think what’s been really nice in our conversations in Rotherham is there’s been a real great shared understanding of why we need to do this and why this is a really good thing across all parts of the health, local authority and voluntary sector. And that surprised me actually, how quickly we came to that shared understanding. And then yeah, the tricky thing then of working out how you then put some detail onto that at some place. We’ve definitely done the same thing – we started with what do we want to do first and how do we make that work afterwards? And I think, you know, we’re at that point where we’re just moving into that – conversations to how we actually make that work in nuts and bolts now.
Andy Brooks
Yeah, seems like a good place to start, doesn’t it? With thinking about people in their community, what can we do to help them? Richard.
Richard Carr
Yeah, I was just going to comment on that. The money comment, it’s often, it’s been a testing part of all conversations around neighbourhood and it’s always – absolutely right – we start with the patient, but exactly to your point, at the end of the day, the money needs to come into the conversation. Because, to achieve those three goals of the long term plan, we need to be able to demonstrate through this way of working in some form a financial benefit that is realising and it’s a tough conversation to have, because obviously we’re going to have to create the case ourselves for why money needs to shift leftward as we try and move care leftward on that patient pathway. And as part of evaluations, I think moving forward in the next year or two, we’re going to have to start thinking, how do we, you know, tag a financial value to some of the benefits that we are seeing? And ultimately, and unfortunately in my view, it’s going to lead to us having to, you know, come up with service activity metrics that then you can a tag of value against, and really demonstrate to acute colleagues and teams how do we work together to shift money with the patient and where we want to care for that patient.
Andy Brooks
Thanks, Richard. Sarah, do you want to come back on this point?
Sarah Everest
Yeah, I think it is, the money is always an important point and I think it’s, for me, there’s something about how we hold our nerve with some of this because a lot of what we’re trying to do is very much long term, large scale organisational change and we might not see the benefits for years to come in terms of population health improvements, but yet the NHS loves a metric to measure and quite often that’s how people get or organisations get paid. So how do we balance off that kind of long-term population health improvement, holding our nerve whilst also ticking the box or removing some of those boxes that need to be ticked?
Andy Brooks
Yeah, and it’s a good question, Sarah, and do you have an answer to the question?
Sarah Everest
No. Well, I don’t get too involved in the box ticking. So, from my perspective, because I work in the health and care partnerships, I’m working on behalf of lots of different organisations. I’m not bound by an individual organisational contract that has those boxes to tick, but I’m fully aware that I work with multiple organisations that do and have different boxes to tick and different metrics that don’t necessarily all come together. So, we need to remove some of that. We need contracts that are joined up. We need outcomes that are collective. And if we can get to some of that, then we’ll hopefully remove some of this individual organisation metrics that are driving some of the activity and behaviours, I guess.
Andy Brooks
It is a tricky topic. It’s also not just with NHS. With NHS there are different bits other than you add in social care and public health and voluntary sectors, different cultures, different ways of doing things, different things important, different languages. That’s why these things take time. Lucy?
Lucy Falcus
Yeah, I think Sarah was exactly right that we’ve got to think of long-term goals here, which, you know, it means that we do need to hold our nerve with the changes we make, not seeing necessarily financial gains immediately. I was always told not to overestimate what can be achieved in a year, but underestimate what can be achieved in five. And I think that’s really important here.
Also, another little phrase is – ‘if nothing changes, nothing will change.’ And I think we’ve maybe been guilty of not making enough changes in the past or making changes that we think will have immediate benefits, but that will never achieve the sickness to prevention agenda because by definition, prevention needs a bit of time to prevent whatever was going to be prevented. So, I think we shouldn’t let that put us off, you know, doing what we think is the right thing for our patients. And as Sarah said, hold our nerve, the financial flows will have to change, but it’s not going to be this year.
Andy Brooks
No, good points. I was wondering, given we’ve talked about working with community groups or patient groups, however we want to describe them, and different organisations, be they in the NHS or local authority or community, I was wondering whether perhaps you could share something that you’ve learnt that’s changed your view by either talking to other organisations or by talking to groups of patients that’s affected perhaps where you’ve done things – Lucy.
Lucy Falcus
Yeah, straight away. So, our multidisciplinary team huddles have had a representative from Citizens Advice every time. And certainly, I’ve been amazed at the range of services they offer. And almost every patient we’ve discussed, there has been something that Citizens Advice can do for them even if they’re not apparently in financial difficulty or have a big issue at the moment. And I think by putting people in the same room or even on the same virtual room, we’re learning so much about each other and the scope of what everyone can do that we are then using each other for maximum effect for our patients. So, I just think drawing us together is a fantastic way of us all working better together for our patients.
Andy Brooks
Thanks, Lucy. How do you cultivate a culture of shared accountability across organisations with separate governments, even potentially if they’re working in the same building? Sarah.
Sarah Everest
Yeah, I think it’s really important as part of this work that we focus on organisational development. So how, so cultures within organisations, how people are working together. Just because people are co-located in a building doesn’t mean to say they’re going to interact any differently. They might be sat in separate rooms. It’s how we do that as part of this. And I think some of the important stuff is how organisations come together to share training. Quite often, training is done separately between organisations. So how we start to do more things together as partners rather than as individual organisations, which I think will help develop that kind of shared culture and accountability.
Andy Brooks
Thanks, Sarah. Richard?
Richard Carr
Yeah, I was just going to build upon something I mentioned earlier in regard to this, with some of our cohort that we’ve identified as being really prime for working with them in a more preventative way through a local healthy living group in the community. They have, they’ve been oversubscribed, they’ve filled their classes, their exercise classes in the community in next to no time. And we’ve built a really strong relationship from across our different organisational boundaries with this healthy living group to think, how do we utilise that group more in the future and how do we think about signposting more people in creative ways and to that organisation, improving exercise in that cohort we’ve identified, but also thinking about the loneliness aspect and bringing different parts of the community together. And so, it’s helping to build like a socially cohesive kind of group, which is bringing multiple benefits across the community as well as our different organisations.
So that’s part of it that for me. I did anticipate that being successful, but I didn’t anticipate it being as a resounding success as it has been, and all the feedback questionnaires that the residents have done have really backed that up, so it’ll be a really interesting part of our evaluation.
Andy Brooks
Yeah, thanks, Richard. Thanks for sharing that, Sarah.
Sarah Everest
Yeah, mine’s similar to Lucy’s. I think having the voluntary sector organisations as part of our regular huddles has definitely brought a much wider consideration about the person and the person’s needs, you know, thinking more about the kind of psychosocial side, not just on the medical side. And I think raising the profile, I mean, we’ve got a fantastic VCSE sector in North East Lincs and I think raising the profile with our health and care colleagues has been great – particularly parts of our health that colleagues that don’t necessarily know what is out there and having people in the room and starting to build those, or virtual rooms, starting to build those relationships and understand what other organisations can do to support people. So we might be talking about an individual in one of the huddles, but then the hope is that if the GP has seen what VCSE organisation Friendship at Home can do for that person, when they go back into base thinking, actually, I’ve got three other people that might be able to be supported by that organisation.
And I think how we do more of that and get more voluntary sector organisations involved. I think one of the challenges, going back to the money that we talked about earlier, is we’ve very much gone with the willing and having VCSE organisations that are happy to work with us flexing their existing contracts for no additional funding has been fantastic, but that’s been great whilst working on a relatively small scale. As we sort of want to scale this up, that’s not sustainable and it’s how we properly resource and fund the voluntary sector organisations to continue to do some of the great work that they do.
Andy Brooks
Thanks, Sarah. Lucy, Do you have an example of how a patient or personal experience has been improved with neighbourhood care?
Lucy Falcus
Yeah, so one of the very earliest patients we brought to our multidisciplinary team meeting was a lady with a chronic condition that has regular flare ups, for which she’s under a hospital specialist. Now, despite one of the long-term mains being going from analogue to digital, we’re not there yet with patients knowing exactly what the next hospital clinic appointment is and what it will involve and what exactly they’re waiting for. So as part of the multidisciplinary meeting we had alongside addressing the well-being aspects of this condition, financial aspects of the voluntary sector, when we talked about her health, a lady from the acute trust said that they could establish what this lady was waiting for and when that might happen, just to give that patient a realistic idea of how long things are, which really helped settle her mind about when things might happen. So, we didn’t jump her up the queue. We didn’t, you know, do anything that was advantageous above another patient, but she just was settled knowing exactly what’s going on. Now, eventually we can get this better in our digital capabilities, but when we went back to the patient and explained to her exactly what she was waiting for and what specialist reviews she’ll get alongside the package of other things we were offering. Her exact words were that we’d moved heaven and earth in how she felt. And so that was really heartwarming as a really early case study.
Andy Brooks
Thanks, Lucy. It is a great story. It is great to get that feedback, the positive effect that these sorts of interventions and programmes can help for individuals, which is, I guess, what we are all here for, working in the health service. Richard, did you have something on the similar topic?
Richard Carr
Exactly, very similar in regard to patient experience. Following some of the proactive assessments that our team have been going out to see various patients and following up with one of those patients, I asked how they’ve found the process of being involved in this kind of way of working and they said very similar. They felt very reassured and extremely happy to be approached in this way. And the fact that that had triggered a referral onto the community rehab team to assess for more equipment around the house to help, you know, impact and reduce that risk of future falls, they had felt had been hugely helpful, really helped their confidence. And they were also very keen to be a part of the exercise programme that I mentioned earlier in the podcast about trying to get involved more in the community. So just through that one intervention of my colleague going out to visit them, in the community – it made them think about their health in a different way and their wellbeing and they were fully engaged with that way of proactively being assessed. So really positive and that story has been repeated in similar forms across multiple patients I’ve spoken to.
Andy Brooks
Thanks, Richard. Again, a great story. At NAPC, we found two of the most important measures are personal patient satisfaction or activation, and also staff activation and satisfaction. Focusing on those two measures is a really good way of building confidence and the direct links with quality of outcomes with those two measures is important. So great to hear those two stories.
What I was wondering, I’m going to ask each of you if that’s all right, a couple of questions so you can have a little time to think about. And the first one would be, you’ve been doing this for a little while. What’s the one thing that you are planning to do next as part of your neighbourhood implementation? What’s the thing that’s coming up that’s on your radar to do. And then what’s the one piece of advice that you might give to other areas of the country that aren’t part of this pilot? So, it may be a piece of learning, it may be a do, it may be a don’t do this, but one piece of advice that you could share with other people. So, the first thing is what’s coming up next and then pause and then if you give me
What’s your piece of advice, Lucy?
Lucy Falcus
Yeah, so what’s coming up next in terms of Stockton and Hartlepool? We have been so enthusiastic about neighbourhood health in our Stockton pilot project that we’ve actually started a very similar looking project in Hartlepool, even though that wasn’t chosen to be a wave one site, because we do think this is something that will work.
But we feel really strongly primary care needs to come along and work at the heart of this, because primary care is in every community, every patient just about is registered to us. We need to take primary care with us. So, what we’ve done as GP Federation is we’ve invested in 9 local GPs who will each take a lead in an area of neighbourhood health that interests them. So, we’ve got a GP with a specialist interest in a hospital specialty that has long waiting lists around here. So, they’re going to think about what neighbourhood health could bring to solve that problem. We’re thinking along the lines of women’s health hubs with the aims of looking at preventing conditions that will end up on a gynaecology waiting list. So, I think my one piece of advice, as well as what we’re doing, is bring people with you because in no area will a handful of people manage to achieve this for the whole area. It’s really important people understand the vision of what changes are needed and why it’s important. And once people catch a vision, then they should, generally, be more willing to make changes, adapt their ways of working and come alongside. So, I think it’s so important that primary care is at the heart of this, that we really need to enthuse our colleagues. And so, in this area, we certainly will have 9 ambassadors going back to their practices and then neighbouring practices to really get us all on the same page and moving forward together.
Andy Brooks
Thanks, Lucy. I’m conscious of the time, so we’ll get everybody have a chance. So, one thing about what you’re going to do next and one piece of advice. Sarah.
Sarah Everest
So what we’re going to do next is develop our plan for scaling our integrated neighbourhood working. We’ve got some really good projects, but we’ve always struggled to embed them to then scale it up. So, and that will include all the things of sort of how the benefits and the costs because we want to explore kind of additional resource as well as using our existing resource a little bit differently. So that’s kind of our next big thing. Piece of advice, the relationships are key but go with the willing. It’s hard work and actually start with those people that can see and share the vision and start there.
Andy Brooks
Thanks, Sarah. Simon.
Simon Langmead
Yeah, where are we going next? I think we’re already turning our minds to what’s after the pilot. The pilot’s just a start, really, isn’t it? And how do we take the good things that we’re doing already and actually build into those? And lots of those are things we’ve already talked about today, the relationships, the structures, the willingness to make this better for people in the communities that we serve.
A piece of advice, I think probably get the right people around the table is probably what I’d say, which I know kind of fits with what we’ve been talking about already. But, you know, in those conversations, you need time, you need support, you need to be honest and open with each other about your challenges and limitations. And through that, I think hopefully partners can learn to trust each other and actually, you know, work together on these shared goals, I think.
Andy Brooks
Thanks, Simon. Richard?
Richard Carr
Yeah, I think the next thing we’re planning is similar to Sarah is about how to scale, how do we scale this and incorporate other existing services in the community to think in the same way that we’re coming around the same model of working. So, bringing in other parts of our unplanned care team in the community, our proactive care team that already exists and coming around a shared strategic vision about how this goes forward as one single neighbourhood to try and combat some of those duplicated visits, etc. And then one piece of advice, I think similar to some of the others again, so really, yeah, build those relationships with partners across secondary care, primary care, community care, VCSE partners, social care -and go with the willing, reach out and have those discussions, be up front about those discussions and people will be with you.
Andy Brooks
Thanks, Richard, great piece of advice. So, I’d like to thank Richard and Simon and Lucy and Sarah for coming and sharing your expertise, what’s been happening in your various patches so enthusiastically. I’m sure we could have made this podcast last several hours. We only really touched the surface on all the great stuff you’re doing and the learning that you could share. It’s been great to listen to all the things you’ve said. Thank you again for being part of this programme. You’ve all shared all sorts of stuff that you want to be getting on with, and you know, we wish you all the best when you do that through the programme. And thank you for sharing your tips for people who are listening to the podcast as they go on with us as we implement neighbourhood care.