1. The Frome MODEL OF ENHANCED PRIMARY CARE
Hello my name is Helen Kingston
I am a gp in the southwest of England.
And I have come to share our story of how building from the grass roots we have worked together as a community
Compassionate Frome a new era of medicine
Dr Helen Kingston

2. A new building and fresh start 2013
I am senior partner at Frome medical practice
In 2012 we all moved to a brand new building with our mental health team community nurses health visitors and neighbouring practice
We were determined to ensure that this opportunity to work together would lead to better care and better integration

3. Frome Frome is a market town of 26,000
It was founded on the wool trade and at one time was as larger as its close neighbour Bath
It has a mixed architecture with a an old centre and larger more modern developments surrounding it.

4. MADE DIFFERENTLY
Frome has an indepdendent town council-made differently is their slogan
They are focused on working with us to improve the wellbeing of our population and not afraid to thing outside the box and do things differently.

5. Frome- small enough to innovate large enough to operate at a new scale.
We are a small part of Somerset county-10%
We sit on the edge and refer to Bath for our main hospital
This made us nimble and small enough to take risks in innovation but large enough to make a difference

6. And of course it is not the bricks and morter that make a place it is the individuals who make our community

7. What is most important? Practical Emotional Medical
Recognising the value of relationships and of the whole system working together- creating integration across silos
So what did we do

8. A Population based approach
Systematic
BASED IN AND PART OF PRIMARY CARE
Whole population not cohort {no inclusion or exclusion criteria}
Based on clinical assessment of need
Holistic
Collaborative

9. Hours with NHS / social care professional = 5-10 in a year
NEWS
Loneliness and social isolation are harmful to our health: research shows that lacking social connections is as damaging to our health as smoking 15 cigarettes a day (Holt-Lunstad, 2015).
Self management
= 8,750-8,755 hours a year
Hours with NHS / social care professional = 5-10 in a year
Working with you to build healthy, supportive communities

10. The comparative impact of social relationships on reduction in mortality

11. IMPACT Improving patient care Improving working lives Cost savings
We wanted to improve care
We knew this would improve our sense of agency as health workers
The cost savings that resulted were not our driver but do indicate this is not only a better way but one that is sustainable in these difficult times

12. Collaborative Problem solving
Complicated lives
Recognition of the complicated nature of human beings and of the interplay between social, psychological and medical need
Responding flexibly to the person not their medical conditions- helping individuals to navigate the system
At the heart of our philosophy was recognition that life is not simple and predictable

13. CLINICALLY LED
Lead from the front line with flexibility to respond to the realities they face
Pragmatic
Solutions focused
Outcomes driven
There are no management costs in the programme. Clinician time is required to implement the project but there is no overarching management of this.
We began by helping those whom we saw were in most need
Not checklists of inclusion or exclusion criteria
If the individual in front of us had needs and was willing to engage we started there

14. IMPROVING WORKING LIVES
Empowerment of compassionate flexible patient focused response to individuals in need.
Creating an integrated cohesive team working across agencies
Recognition that those at the front line are motivated through their desire to help others and improving working lives through enabling them to provide the care they would want for their own family and friends.
And of course the benefits are not just felt by patients
Health workers felt a moral distress witnessing suffering and not trying to address that

15. QUALITY IMPROVEMENT
Use of quality improvement methodology to measure and drive effective change. A lead GP in each practice is mentored on a monthly basis in quality improvement methodology, which determines the direction of the project in each practice. This has meant there is rigorous methodology with use of run charts to track process and outcome measures. It also ensures local ownership
We have spread this approach across the broader Mendip area with each new practice recruited identifying a champion

16. An example of continuous improvement using QI
It takes a while to embed but the project is now beginning to scale up

17. WHOLE SYSTEM APPROACH Collaborative intergrated working
Changing how we work across local health service
Integration and collaborative team building
Breaking out of silo working
Wrapping care around the individual
Recognising the importance of relationships for those working in health and for patients and carers
Building a strong team ethos
Supporting patients and carers
Supporting those working within the system

19. WHAT MAKES LIFE WORTHWHILE
Understanding what matters to patients
Treating staff with kindness too and recognising that we chose to work in health and social care wanting to make a difference
Reenabling staff to deliver the care they can feel proud of and that would want for themselves their families and friends

20. Working together to help build healthy
supportive communities.

21. OUR MODEL Health Connections Mendip Practice population of 115,000
11 GP practices
Health Connections Mendip Team employed by Frome Medical Practice on behalf of the 11 Mendip practices
2 FTE Area Lead who line manage the Health Connectors and lead on the community development in their area (paid
6.5 FTE Health Connectors (paid) Work one to one and support groups that we have set up
551 Community Connectors (not paid but people in the community)
We have a small team funded through health to help us
But the community approach means that our reach can be extended
Working with you to build healthy, supportive communities

22. Practice population of 115,000
Service Lead (and East Mendip Area Lead)
Line manages Area Leads, Community Connector Lead and East Mendip Health Connectors and does Community Development work
5 days a week
West Mendip Area Lead
Line manages West Mendip Health Connectors and does the Community Development work.
4 days a week
Practice population 50,000
Health Connector
1 full time equivalent
Central Mendip Area Lead
Line manages Central Mendip Health Connectors and does the Community Development work
2.5 days a week
Practice population 20,000
Phone Health Connector and Admin Lead
Covers whole service
4 days a week to support Mendip Symphony extra workload to cover Central and West Mendip
East Mendip Area Lead
Line manages East Mendip Health Connectors and does the Community Development work
5 days a week (same person as Service Lead)
Practice population 45,000
Community Connector Lead
Trains Community Connectors and supports the Area Leads with new projects
(2 days funded by Town Council)
344 Community Connectors!
Practice population of 115,000
Employed by Frome Medical Practice on behalf of the 12 Mendip practices.

23. MAP
We start with the assets in the community
Overview
- its opportunities and strengths. We map local support and let people know about this support in a variety of ways. We 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.
Number of practice based signposts easy to report on across the 12 practices.
Website template is replicable so other areas can use it.
Over 32,000 views
So we began by mapping what was already there
Working with you to build healthy, supportive communities

24. COMMUNICATE There is so much support out there
Overview
Phone line manned 5 days a week
signposting
Letters to patients on practice register
Newspaper articles
Monthly radio slot
Awareness raising stalls
Website over 32,000 views
Staff who link to the website via EMIS eg GPs, Health Connectors , Health Care Assistants and Receptionists
Talking Cafes
Community Connectors
We recognise that people access support and information in different ways. Our model enables people to find information in the way that suits them best.
We let people know about support in a variety of ways.
Spreading the word
Working with you to build healthy, supportive communities

25. Embedded in EMIS so social prescribing at fingertips

26. CONNECT 551 Community Connectors.
If each Community Connector signposted 20 times a year this would be 11,020 opportunities to support people in our community.
11,020 signposting conversations a year.
The number of Community Connectors is ever increasing.
And building a network of community connectors. Interested individuals in our community who knew about our website and the service who could help to spread the word.
Working with you to build healthy, supportive communities

27. Connect .
Who would make a good Community Connector?

28. Connect
Community Connectors are members of the community who know what’s out there and signpost friends, family, colleagues and neighbours to support in their own community. Community Connectors are very effective at integrating with their local communities - providing a bridge between local people and other services and thus building community knowledge.
700 Community Connectors
Thousands of people signposted to support.
Church congregations
Supermarket staff
Hairdressers
Sixth form students
Support group members and patients
Drug and alcohol peer support workers
Police Community Support Officers.
Care home staff/care workers
Taxi drivers
Park Rangers
Town Councillors
Social Workers
Job Centre Staff

29. BUILD
Support vol sector development by finding volunteers eg Contact the Elderly, Health Walks, promoting eg Parkinsons Support Group and Somerset Sight.
Act as catalysts eg volunteer driver scheme, mental health network.
Invite organisations in eg - Bereavement Support Group
Encourage eg Men’s Shed
Bringing people together eg ASC, My Home My Life and CAB (Practice of the Year)
Being open to ideas eg Housing post, Youth PPG
Train eg Compassionate Organisation , network mapping
Put on big events - eg Older People’s Event (topic based)
Innovate eg Advance Care Planning Conversations in the community
Start partnership campaigns eg End Loneliness in Mendip .
- In Partnership
We don’t just set up self sustaining groups but we can support community development in other ways.
Working with you to build healthy, supportive communities

30. Building Social Capital
Just a few examples
Setting up self sustaining groups – Identify and Invite - Macular Degeneration Group
Promoting new groups via identify and invite – Parkinsons.
Inviting in - Bereavement Support Group and Walk and Talk
Being a catalyst– car scheme, mental health network
Bringing people together – ASC and My Life My Home.
Doing the simple thing – Hearing Service, Retirement Gateway “Health Connections has been invaluable in bringing together NHS commissioners and voluntary organisations to map the support available for patients with hearing difficulties. Work is progressing on identifying gaps in provision, and planning ways to support people that may be ‘falling through the gap’. Health Connection’s experience in working with the voluntary sector has been a real asset, sharing ideas for raising awareness and promoting joined up working for the benefit of patients.”
Finding volunteers – Contact the Elderly “It has been really useful being able to team up with Health Connections to help raise the profile of Contact the Elderly, and help recruit new volunteers to enable us to get two new groups going”.
Promoting services – Somerset Sight Volunteer Visiting Service “We have been most impressed with the ability of Health Connections Mendip to promote a local service so quickly and with so much impact across the whole county and would like to say a big thank you”
Being open – Housing post
Peers doing it best - Advance Care Planning in the community, Youth PPG
Starting bigger campaigns – End Loneliness in Mendip.

31. Building Social Capital
Promoting services – Somerset Sight Volunteer Visiting Service “We have been most impressed with the ability of Health Connections Mendip to promote a local service so quickly and with so much impact across the whole county and would like to say a big thank you”
Being open – Housing post
Peers doing it best - Advance Care Planning in the community, Youth PPG
Starting bigger campaigns – End Loneliness in Mendip.

33. Stats
81%* of (HCM) patients saw an improvement in wellbeing (WEMWBS) 83%* of patients saw an increase in PAM score (patient activation)
PAM score (initial) average Pam score (follow up) average 61.6
PAM level (initial) average 1.9. PAM level (follow up) average %* of patients said they felt more able to access support in the community 94%* of patients said they were more able to manage their health and wellbeing or LTC 92%* of GP practice staff feel confident that their patients benefit from being signposted to HCM 91.4%* of GP practice staff feel that HCM adds value to the service they provide to patients
Plus recording done by wider Mendip Symphony team. eg hospital admissions.
*based on those that answered

34. Why it works One foot in the community, one foot in primary care.
Employed by and work for the 12 Mendip Practices. Practice pop. 115,000.
Work on new models of care. Mendip Symphony patients and attend MDT meetings – Complex Care, primary care, hospital and Adult Social Care this helps us get the bigger picture.
We have a shared EMIS clinical service across the 12 practices where Complex Care GPs, Nurse Practitioners, HCAs and Health Connectors can all input on to the shared care plan.
We work on community development.
We work with groups and individuals on what is important to them. This may involve goal setting, behaviour change, managing LTCs, linking to the community, network creation, network mapping and network enhancement and/or signposting to other services.
We work with people with complex needs through to those keen to maintain good health.
We work across the whole community – out in the community, in people’s homes, in primary care, in hospitals.
Self referral and referral.
Work with the whole community from a young man who is feeling anxious and wants to get a job to an older person who is housebound, has had falls and has lost contact with her family.
We are trusted
We do what is best for the patient
We are allowed to be creative
We make mistakes and learn from them
Patients feel it belongs to them.
Staff enjoy their work.

35. Financial Impact Background
3 years of implementation of the Frome Model has shown a year on year reduction in the number of emergency admissions and the costs of those admissions.
CCG data suggests Frome Medical Practice has seen a decrease of 160 emergency admissions (-6.2%) when comparing the full 2017/18 year with the baseline (2013/14).

36. 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.

37. WHOLE TEAM APPROACH Integrated working
Patient empowerment and carer support
Network enhancement
Primary care
Community services
Social care
Voluntary sector
We can achieve so much more working together across sectors to support the individual than we can as individual organisations

38. LESSONS LEARNT We can achieve more together than as individual teams
Don’t underestimate the power of relationships- within teams and for our population
Scaling up requires
Systematic approach
Capacity for multidisciplinary conversations
Take a holistic approach stating with what is most important to the individual.
Support carers
DO WHAT IS BEST FOR THE INDIVIDUAL WORKS