“One in four of us is living with a long-term health condition and/or diagnosable mental health problem”. (Nesta, 2016) 40% of GP appointments now involve mental health and 90% of people with mental health problems are supported solely within primary care settings (Mind, 2018). Loneliness and social isolation can be as bad for patients with chronic health conditions, with a GP seeing up to 5 people a day who are lonely (RCGP, 2018).
With an ageing population and increasing numbers of patients with multiple medical problems, the pressures on general practice are growing.
Nesta suggests that a bold new approach is needed in order to meet these challenges; “we need an unconventional new approach in how we design and deliver health and care services that put people in the lead, uses the resources in our communities, and embeds co-production as a core principle.”
With 85% of people visiting their GP every year, GP surgeries are in a great position to engage with their patients, carers and communities to help realise this vision.
The GP Forward View (NHS England, 2016) includes patient wellbeing and self-care at the heart of their proposals, and two of the Releasing Time to Care High-Impact Actions are designed to reduce GP workload (1. Active signposting and 9. Supporting self-care).
Churchdown Surgery in Gloucestershire has recently moved into new, state-of-the-art premises in the middle of their practice area next to the local Community Centre. The practice area is largely suburban with a few outlying villages. The practice cares for many middle-income families, but there are also areas of affluence and social deprivation. The practice list size is 13,851 and growing.
Despite being a popular practice with high patient satisfaction, the staff are tackling an increased workload – from patients struggling with multiple chronic diseases, frailty, loneliness, and mental health problems. It is apparent that many of these patients find it difficult to make lifestyle changes and engage with sources of support.
- 57.6% have a long-standing health condition (England average 53.5%). 360 patients have pre-diabetes, 754 patients have Type 2 diabetes.
- 21.4% of the practice population is over the age of 65 (England average 17.3%). In the 2001 census, 495 pensioner households had no access to a car or van, and 674 pensioner householders were living alone. 110 people are coded as having dementia, and 2,854 people registered in the practice are over the age of 65.
- 20% of the practice population, 2,754, are recorded as BMI > 30.
- 92% of respondents to the 2017 GP practice survey would recommend Churchdown Surgery to someone new in the area (CCG average 83%, national average 77%).
The practice is keen to move away from the old-fashioned focus of a GP surgery focussing on illness to a practice embedded and connected to the community with a focus on empowering patients to look after their own health, support each other and their community.
Three potential patient groups have been identified as priority areas, along with supporting carers for people in these groups:
- Adults living with diabetes or pre-diabetes.
- Young and working-age people with mental health conditions.
- Older people experiencing loneliness and social isolation.
By mapping the assets in the community and matching them to health needs from practice data, Churchdown Connections will adopt and adapt new models in place in other areas in the country, for example, Compassionate Frome and Health Connections Mendip to create the connections between the health needs of the community and community-based assets.
Models such as the Quadrant model piloted with diabetes care (Hart, 2018) can be used to segment people to ensure that their needs are matched to the appropriate level of intervention.
A member of staff will receive training in health coaching to help patients (and carers) identify peer support groups in the community relevant to their own individual perceived physical, social, or psychological needs. This “Community Connector” would be available for immediate coaching conversations for patients attending the surgery or if recommended by their GP or practice nurse.
Volunteer peer support champions will be recruited to support patients to attend groups for the first time (often a block to the effectiveness of peer support activities as highlighted by the Q labs work). There is evidence that becoming a peer support champion has health benefits such as better knowledge and awareness, increased self-esteem and confidence, and improved well-being. For some individuals, this will be the start of a journey to other opportunities such as education, volunteering roles or paid employment. (Altogether Better).
What is health coaching? “Health coaching is a patient-centred process that entails goal setting determined by the patient, encourages self-discovery in addition to content education, and incorporates mechanisms for developing accountability in health behaviours. The evidence is that there are many benefits associated with health coaching”. (Better Conversations Resource Guide).
A steering group of stakeholders comprising the Community Connector, representatives from the patient participation group, Churchdown community centre, Gloucestershire Community Wellbeing Service and cluster Community Frailty matron would meet regularly and work together to facilitate a streamlined experience for patients, avoid duplication of work, and share resources and learning.
The premises offer new opportunities for promoting patient well-being and self-care; the building is surrounded by land that would be suitable for a small community garden, which could offer a space and a reason for people to socialise, learn, be active, and grow food together in a safe, secure and supported environment. This could also include participatory arts, e.g. social sofa.
There is a multi-purpose room with a sprung floor suitable for exercise classes or peer support groups. A pre-diabetes education lifestyle group, Kernow Yoga for back pain, Pilates classes for the staff and/or patients are all possibilities. These would enable a wider focus on aspects of mental health, social isolation, and giving a space for inter-generational peer support.
Potential interventions might include a diabetes walking group. As buses to the practice only run once an hour, there are long waiting times for patients, and the community centre is already creating a space for a café for people to use when attending the surgery, which will provide a space and opportunity for conversations and peer support.
The Q Lab also found that promoting and finding peer support services can be challenging and so through mapping and then support a hub of resources this will enable easier connections between people in need and services available to support.
If successful we would hope to disseminate our ideas widely within our locality and the Q community by developing an online toolkit for other practices/ CCGs to utilise.
Our approach as a project team with the support of the Q community and Q exchange would be:
- Discover (September 2018 — February 2019) — data gathering of health needs, community assets, liaising with Gloucester Public Health and existing community champions, learning from exemplary sites, and recruiting a “community connector” to lead this work.
- Co-design (October 2018 — March 2019) — Provide health coaching training to the ‘community connector’, recruit and train 10 champions with lived experience in the priority areas, facilitating co-design sessions with staff, Patient Participation Group, and the local community, and training the whole practice team in coaching skills.
- Deliver (February 2019 onwards) — tests of change following the quality improvement approach, measuring for improvement defining measures, for example using process (number of contacts and connections), outcome (patient satisfaction, patient activation measure (PAM) levels, and clinical outcomes), and balancing (staff satisfaction, number of GP attendances) measures. Our discovery phase will include scoping measures and collecting baseline data.
- Evaluate and share (July 2019 onwards) — share results with the Q community and other areas who would like to implement this model through a blog and social media, and an implementation toolkit for the spread.
The funding offered by the Q Exchange will give backfill to enable a team of practice staff to carry out the activities above, scoping, data gathering, and co-design activities with members of the local community, as well as fund visits to exemplary sites (e.g. Frome, Bromley-by-Bow), training in health coaching conversations, and remuneration to patient champions.
How you can contribute
- Leave a comment -- what do you think of this idea, can you help us?
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- We are looking for:
- Experts in peer support, community-based asset mapping, and social prescribing to act as an advisory faculty for the project team.
- Networkers to make connections with similar projects in other parts of the country.
- Critical friends to provide challenge particularly in relation to measurement and evaluation.
- Promoters to act as a champion for the project and to share learning from the project team as the project develops
- Fixers with specific areas of expertise particularly seeking support in setting up a directory of services, in facilitating a co-design workshop, in providing improvement coaching to the project team, and in identifying appropriate training to meet identified training needs.
- Visits to exemplar sites will be arranged as Q visits and open to members of the Q community to participate. Learning from exemplar visits will be shared with members of the Q community through the Q website.
Evidence base (DOCX, 30KB)
This is a great project because…
It's a well developed example from primary care taking a community assets approach looking holistically at the mental and physical health needs of patients.
By the time of the event we encourage the project team to think more about…How you will build on and connect with other work underway in this territory and use the Q community to share learning throughout the project.