Whole Population, Neighbourhood
Focused Healthcare
Introduction
The challenges facing the UK with regards to both the health and wellbeing of the nation and the state of our statutory services are well known. Radical transformation is needed that focuses on the whole population and all parts of society engaging in this challenge together.
This proposal outlines an approach to transformation that in addition to health and care interventions, centres solutions on civic society, neighbourhoods and reducing loneliness.
Whilst people are living longer, they are not necessarily living healthier and live many of their years with multiple conditions. Many of the diseases that people are living with have roots in environmental and lifestyle factors. Furthermore, the impact of social isolation is a key component of the ill health of the nation, both how that impacts physical and mental health.
Compassionate Communities UK has access to solutions from across the world via its networks to bring innovative options to many of the challenges faced by health and care organisations with regards to palliative care, primary care and chronic disease management.
All elements of our Whole Population, Neighbourhood Focused Healthcare are set within the New Essentials Model of Care diagram below.
Whole Population, Neighbourhood Focused Healthcare
The model of whole population requires all four ‘cogs’ from the diagram above to be working effectively together. There are of course interventions that require specialist care, and much support that can be provided in generalist care. However, critical to the system working is the development of compassionate communities and civic programmes of health promotion, prevention, harm reduction and early intervention. The challenge for whole system change is working on each of the cogs and making sure they are fully integrated with each other.
Those people experiencing serious illness or supporting those that are, need the support of their personal networks, employers (where relevant) and their communities. A civic programme is essential in ensuring that all parts of society have the confidence, competence and where relevant policies in place to support a health promotion / crisis prevention health and care strategy.
With the system working effectively evidence demonstrates that health outcomes improve in a variety of different areas. In an effective whole population system approach, loneliness is reduced, and people remain more active across health domains. This has a beneficial impact on both physical and mental health. This in turn reduces the utilisation of health services. Health services reform which fails to have a significant impact on community connectedness and belonging simply shift resources from one part of the health and social care system to another, without addressing the problems of increased healthcare usage. The government of 2004 tried to reduce hospital care by investing in primary and community care. The lack of investment in community development so a 42% rise in emergency admissions to hospital over a 12-year period with catastrophic consequences for the whole of health and social care systems.
Taking a whole system, whole population approach reduces overall healthcare usage, as has been shown with the Frome Model and its modification in the southwest cluster of Cardiff. No other examples of exist of whole population emergency admission reductions.
There are 8 critical components of Whole Population, Neighbourhood Focused Healthcare utilising the New Essentials Model of Care: -
1. Integrated Neighbourhood Teams
2. Primary Care Transformation
3. Talk Listen Connect Community
4. Citizen Connectors
5. Treasure Mapping
6. Compassionate City Charter
7. Quality Improvement Processes
8. Outcomes Framework
Integrated Neighbourhood Teams
Integrated Neighbourhood Teams (INT) developed properly, alongside the other elements within our programme can radically shift both the outcomes for citizens as well as the utilisation of healthcare services.
Key to the successful implementation is a recognition that INTs are part of the landscape and will not achieve all they can, without the other elements in the New Essentials Model of Care.
We can support you in developing a programme plan for the implementation of INT that recognises the similarities and differences within the different healthcare systems and populations. Our approach considers models of INT implementation, use of data, organisational development and team dynamics, process mapping, mentoring INT members and most importantly contextualising INT alongside other components of Whole Population, Neighbourhood Focused Healthcare
Primary Care Transformation
There are 2 major components of whole population approach using social relationships through building compassionate communities as a major therapeutic tool.
The first of these is setting up a community development service to enhance and build compassionate communities across a geographic setting, whether this be a rural area, a town or a city. This must include an effective Integrated Neighbourhood Team.
The second is an enhanced model of primary care with 4 major components, some of which are included in this document in more detail.
1. Identifying people who are lonely and isolated who would like to be more connected.
2. Setting up a hub in primary care that is equipped to act on those who need more support. This includes the use of health connectors, time at Integrated Neighbourhood Team meetings and administration support to ensure the smooth running of this work.
3. Enhancement of naturally occurring networks of support around people who are experiencing chronic ill health and serious illness.
4. Linkage to community resource to help people develop the positive relationships with their communities.
Some of this work is already being done by social prescribing but this needs to be contextualised. At any one time, about 20% of people feel lonely and isolated. A well-funded, highly functioning social prescribing team may see 1% of the population. This means that 95% of people who would benefit from a community-based intervention will not receive it if reliance is on social prescribing alone. Social prescribing is a small part of a much bigger picture.
Talk, Listen, Connect
A Talk, Listen, Connect Community is a new local and national movement, operating at neighbourhood level that engages citizens, groups, clubs and organisations in developing confidence in supportive conversations and connecting individuals to local activities. This programme is positioned in the Civic Cog of the New Essentials Model of Care. Evidence from places like Frome in Somerset, demonstrate the power of activated citizens and the difference they can make in combatting loneliness and improving health and wellbeing of communities.
Citizen Connectors
Citizen Connectors are a new role, designed to work on a one-to - one basis with citizens who have no clearly identified circle of care and support. This role is non- clinical and is designed to ensure the postholder has the time to spend with someone with long-term conditions (including
mental health) and their primary informal carer (if they have one). The role aims to support Integrated Neighbourhood Teams where social isolation and breakdown of circles of care is a key component. This is a more enhanced role than that performed by social prescribers, although this is a key and complimentary workforce.
Treasure Maps
A key component of our approach is to ensure health, care and community workers understand the neighbourhoods’ strengths. This is beyond the Directory of Services that many areas have. This mapping identifies many of the clubs, groups and individuals that form the fabric of grass roots communities. We support practitioners to have the confidence to find their treasures and in particular focus equity, diversity and inclusion.
A key component of Whole Population, Neighbourhood Focused Healthcare is a citizen accessible directory of support. This may well be an enhanced version of an existing directory of services. In addition to a digital directory, a programme of communications, leaflets used of civic spaces are key in ensuring that anyone can find out what is happening in their neighbourhood. There are key civic roles and organisations that can have a big impact by having knowledge of local support including hairdressers, libraries, pubs and cafes.
Compassionate City Charter
The Compassionate City Charter whilst focusing on death, dying and loss also supports our Whole Population, Neighbourhood Focused Healthcare model. It is key in helping create the connections between the 4 Cogs in the New Essential Model of Care. The City Charter programme works at three levels i) supporting grass roots confidence and capacity building ii) organisations and system partners working together for a common cause and iii) system and policy change.
The Compassionate City Charter (which is equally relevant at community level) can support agendas such as Healthy Ageing, Palliative and End of Life Care, Dementia and Loneliness.
Key components within the Compassionate City Charter include Compassionate Organisations, Workplace and Place based endorsement programmes.
Despite best efforts, there has not been a significant shift from hospital deaths to dying in the usual place of residence. This is not surprising as access to high quality palliative and end of life care is not equitable with many people not being able to access appropriate support at the right time to prevent crisis.
The number of days spent in hospital in the last year of life is enormous, particularly in the over 75-year- olds.
This accounts for over 800,000 admissions. 77% of these were emergency admissions. Multiple admissions happened in half of those in the last year of life. Reducing unnecessary admissions to hospital is not just a question of early identification of serious illness and better advance care planning. It is a whole system approach, boosting community forms of support, working in partnership with communities and increasing death literacy in schools, workplaces, places of worship and the other areas of the compassionate city charter.
Death, dying, loss and care giving is not a medical event with a social component. It is a social event with a medical component. A whole system approach requires attention to not just the 5% of the time spent with health and social care professionals, but the 95% of the time people spend in their homes, with friends and families, in their community and the other civic spaces as above. This attention is to the person with the illness, but it also includes the supportive networks that surround them. The relationships that happen within the network are a rich source of support to the person with the illness.
Quality Improvement Processes
Our approach is underpinned by a quality improvement process, and we can support system with the implementation of this alongside discussion around governance, data sharing etc.
Outcome Framework
A full outcomes framework is developed collaboratively, however key outcomes include: -
• Improved working lives for clinical teams
• Improved patient outcomes
• Reduction in healthcare usage and reduction in total healthcare cost
• Effective cross organisation working
Who are we
Compassionate Communities UK (CCUK) is a registered charity that is focused on whole population health and system transformation in two key areas: -
1. Primary Care
2. Palliative and End of Life Care
The charity is part of an international movement tackling loneliness, improving health outcomes and reducing the fragmentation that impacts palliative and end of life care.
Headed by Dr Julian Abel, a retired palliative medicine consultant and one of the key architects of primary care transformation in the market town of Frome, Somerset the team is made up of a wide range of associates who have the skills to support system transformation.
Our history and expertise bring together education, community development, clinical expertise, NHS, organisational development, service and workforce redesign and research. We believe we are the only consultancy that can bring together partnerships in all 4 cogs of the New Essentials Model of Care, from community, the civic sector, generalist and specialist care.
We offer consultancy, training and support to health care systems. The main aims of our consultancy programme are: -
1. Improving outcomes in population health and health care
2. Tackling inequalities in outcomes
3. Improve experience and access
4. Enhancing productivity and value for money through enhancing community forms of support reducing the need for health care expenditure, particularly those inappropriately admitted to hospital
Please see Appendix 1 for our list of educational programmes.
Our Approach
Our approach is consistent with five action points of the Ottawa Charter for Health Promotion that highlights i) creating supportive environments ii) strengthening community action, iii) developing personal skills and iv) re- orienting health care services toward prevention of illness (or crisis) and promotion of.
We create a bespoke approach starting with a scoping exercise, however roughly we follow the following stages: -
1. Discovery phase,
We speak to key stakeholders to get an understanding of the way the system operates, what policies / practices are in place. We’d look at key data sets, demographics, pressure points, what the provider and commission landscape is, what community and resources are in place. What the aims and aspirations are of the system and what strategies are in place. What is working well and what the challenges are.
2. Development phase
Following discovery we would seek to create an integrated network (if one doesn’t already exist) to codesign proposals for change. Areas for system transformation would be prioritised. Proposals for change that is possible in the short, medium and long term would be developed across the 4 cogs of the whole population model along with actions and outcome measures. The approach to design builds on any relevant validated tools, self-assessment protocols, and the model proposed for the measurement of sustainable development goals. This phase includes any approvals, presentations and governance stages that are required.
3. Delivery phase
Depending on the programme is developed, action plans will be implemented by the integrated network. This may include completion of education programmes, development of effective integrated teams which are not health dominated, development of new roles, implementation of new protocols, public education, death literacy etc. The teams will be supported via coaching and mentoring during the delivery phase.
4. Evaluation phase
Whole system population-based statistics are used as primary outcome measures. For sustainability, evidence of reduction in health and social care usage must be found. These statistics are already gathered. It is a question of drawing them together to monitor change over time in the form of run charts. At the same time, qualitative evaluation will take place to ensure that the experiences of death, dying, loss and care giving give rise to an increased sense of belonging. Staff satisfaction surveys also play an important part of an evaluation process.
Why now
Lord Darzi’s report highlights what all of us working in heath and care know. The health of the nation has deteriorated with people living less of their life in good health and that we have a sickness service not a health service. There is a need to shift the focus to out of hospital care with health promotion and prevention.
In addition, hospices are demonstrating significant financial challenges, and many are closing services. They are key partners in the transformation of palliative and end of life care and the NHS does not have the capacity to pick up the work that they can no longer do. Hospices also have a key role to play in a compassionate community due to their reach into the local areas they operate in.
CCUK’s Whole Population, Neighbourhood Focused Healthcare approach, integrating of health, care and civic society create the transformation needed to meet the challenges the country is facing.
The single biggest contribution to health, as opposed to disease management, is good social relationships. The 2010 groundbreaking meta-analysis of Julianne Holt- Lunstad showed that the impact of good social relationships reducing premature mortality, was greater than giving up smoking, alcohol, improve diet, healthy exercise and much more effective that the treatment of high blood pressure. If the health of the nation is to improve, then social relationships, and communities, are fundamental to the practice of medicine. Without this, reducing hospital care is no more than a pipe dream.
We use a place-based strategy to develop a landscape of integrated teams who will coordinate their efforts to bring about whole population change to health and well-being, it includes dementia and frailty, across all age groups. It is a grassroots process driven by the people who have lived experience rather than professional perspective. We will help partners produce a comprehensive solution that fits with Integrated Care Board’s local delivery plans. By bolstering community support healthcare usage is reduced, relieving financial pressure and workload on already strained systems. To achieve this, professional development is aligned with community development. Both quantitative and qualitative data will be used across the whole system, ensuring money is spent where it is most needed at the same time as relieving the long-standing problems of inequity of access in trying to deliver a one size fits all model.
Appendix 1
In addition to consultancy, we provide a range of education programmes, further details can be found on our website www.compassionate- communitiesuk.com
Programmes include: -
• Compassionate Cities / Communities Foundation Programme
• Public Health Palliative and End of Life Care for Specialist Registars and the MultiDisciplinary Team*
• The Frome Project
• Talk Listen Connect training
• Certificate in Equity, Diversity and Inclusion for Palliative and End of Life Care*
• Public Health Palliative and End of Life Care approaches to Bereavement
• Compassionate Communities Essentials for Hospices
• The philosophy and sociology of Dying
• Public Health Palliative and End of Life Care approaches to spiritual care
• Treasure Mapping
• Social Mapping / Citizen Connecting
*These courses enable hospice staff to apply for 50% contribution with thanks to Hospice UK