More than just medicine Why do we need a new approach-

Putting it all together The town that gave up medicine

Primary common experience of ill health Increasing fatigue leading to decreasing mobility Decreased social contact-loss of work and role Loss of sense of purpose – meaning and value in life Loss of well being.

The comparative impact of social relationships on reduction in mortality

4 key steps Identifying those in need of support Identifying support needs and what's important to them Ensuring most appropriate support is accessed Link to community networks

Segmenting based on activation/ Health literacy

6 key points Implement all the functions of the model – partial implementation does not work Ownership of change must be in primary care NOT TOP DOWN CHANGE Do what is best for the patient This is clinician led and patient led- not top down, based on experience, shared learning, cooperation and coproduction. ALWAYS use quality improvement methodology for change Employ community development workers as part of clinical team

Shared decision making Self management education Peer support Health coaching Social prescribing Community development Hospital Discharge review Shared care record Quality Improvement Multi Team working

Practice population of 115,000 12 GP practices Health Connections Mendip Practice population of 115,000 12 GP practices Health Connections Mendip Team employed by Frome Medical Practice on 6.5 FTE Health Connectors (paid) Work one to one and support groups. 511 Community Connectors (not paid but people in the community)

Map Nearly 400 groups and services listed. Start with the assets in the community – its opportunities and strengths. Map local support and let people know about this support in a variety of ways. Link patients in Mendip GP practices with non-medical sources of support within the community. This connects people to the assets on their doorsteps. Nearly 400 groups and services listed. Embedded in EMIS so social prescribing at practices’ fingertips. Over 32,000 views 16-17. www.healthconnectionsmendip.org

Connect 511 Community Connectors. If each Community Connector signposted 20 times a year this would be 10,220 opportunities to support people in our community. 10,220 signposting conversations a year.

Build – Self Sustaining Groups When gaps in service provision are noted, draw on the knowledge, ability and resources developing a new service/group would complement rather than duplicate services. Citizens being active collaborators in this process leads to increased local confidence and a sense of empowerment for those involved. Self sustaining groups we have helped patients set up. We often use ‘Identify and Invite’ 100s of people access these groups every month. Leg Ulcer Club COPD Support Group Macular Degeneration Support Group Diabetes Support Group Stroke Support group Multiple Sclerosis Support Group Café Connect for people with dementia and their carers Hearing Support Café MS Exercise Group Meniere's Support Group

Group education and support 5 weekly Talking Cafes. 224 a year. 6 week Self Management Programme. 4 programmes a year. ‘On Track’ goal setting groups. 56 groups a year. 12 week free exercise programme. Ongoing. Retirement Gateway. 12 a year. Minimum of 474 groups run by Health Connections staff a year (excluding those that we help set up to be self sustaining).

Health Connecting Health Connectors Health Connectors offer one-to-one appointments and do care planning Listen to patients and their carers to find out what is important to them Connect people into support in their community Support patients in managing a long-term conditions Assist them in setting goals and making changes that are meaningful to them Network creation, network mapping and network enhancement

So what? What difference does it make?

Monthly emergency admissions Somerset 2013 – 2017 –

Quarterly admissions Frome 2013 – 2017 We sit on the edge of the next great change in medicine. This is so important – the medical model is not enough.

Cost implications of Frome Model Cost of all admissions Frome in 2013 - 2014 = £5,755,487 Cost all admissions Frome 2016 -2017 = £4,560,421 Reduction Frome between 2013 -4 and 2016 - 7 = £1,195,066.  This is a 21% reduction in actual cost between 2013 and 2016   Cost of all admissions Somerset 2013 - 2014 = £86,535,551 Cost of all admissions Somerset  in 2016 - 2017 = £104,804,840 Total increase in cost in Somerset = £18,269,289 This is a 21% increase in costs of admissions in Somerset excluding Frome.  Application of Frome model would have saved Somerset £35 million – total budget £700 million Population 500,000. Money is one of the ways of presenting benefits.

Clinician outcomes Previous situation- Arrive to fully booked surgery, un-triaged. Complaints ranging from coughs and colds, to letters requested for housing, to new cancer diagnosis or medically unexplained symptoms. Extras squeezed in on top. Now- Arrive to clear desk. All demand is met on the day. “Midday Huddle” where all staff – GP’s, Health Coaches, Receptionists, Admin, Nurses and Care- Co-ordinators discuss 15-20 complex patients and agree actions, monitoring and interventions. Also review successes, admits and discharges.

Citizens-Improved quality of life, better health and well being, sense of control Efficiency- Reduced waiting times, reduced demand, improved working lives of clinicians, reduced unwarranted cost Quality- reduced error, improved patient experaince

Thank You