Helen Kingston, GP

Published in JHH15.3 – Social Prescribing

I set up the Compassionate Frome project with Jenny Hartnoll in 2013. As the project has grown and expanded across the Mendips, I also worked closely with compassionate communities.The project was designed to better connect and support patients and improve working lives for those in healthcare. It has also demonstrated cost savings as a by-product of this patient-centred approach. In July this year I was awarded a Point of Light award by the Prime Minster on behalf of the team for the work and its achievements.

Our project began in 2013, partly as a response to patients whose problems required more than medication, but in an environment where clinicians were ever more expected to rely on linear algorithms for single diseases. Each of us is, after all, so much more than a list of our diseases, and these constraints seemed increasingly to distract from what was most important to the individual.

In each one of us there are qualities to love and admire: some of us are more extrovert, more confident and more able to take the opportunities that life may provide us. Our some[1]times contradictory emotions, and the history of how we have become who we are today, are what makes us human. We need to understand each other’s frailties and imperfections and find acceptance, because the connections we make with our fellow human beings are an essential part of what makes life worth living.

When faced with a simple problem most of us can make the right decision. However, someone faced with a complex mix of conflicting emotions, previous adverse experiences and a lack of self-confidence might well struggle to move forward. To help someone in this predicament to make progress we must first understand their perspective and what is most important to them. This will require empathy, listening skills and time to connect and understand. Professionals can help but equally friends, neighbours and family members also have these abilities. and they in turn may be best placed to offer these gifts. By building a more connected community every[1]one benefits, but in particular those who lack connectedness, some of whom are among the most vulnerable in our community.

Reaching out

Our project sought proactively and systematically to identify people who might need this kind of support. For instance we contacted anyone discharged from hospital after an emergency admission, and we set out to identify anyone who – whether at a home visit, or at an appointment – had appeared to be at a crossroads or indeed in crisis. We believed that in such vulnerable times, networks of support either became visible or were most obviously needed, and that the impetus to make a change in the pattern of life could become more activated.

A hub team working within our GP surgery has time protected for carrying out this important work and to offer support. To link up concerns and co-ordinate the care of those most in need, our hub nurse is available for case discussions with hospital staff, ambulance teams and community colleagues. This will not happen if liaison activity has to be squeezed between consultations and phone calls in the normal busy working day. The role provides her the space and time needed for implementing a proactive approach. This allows us to work systematically across our whole population to ensure that we provide consistent care to those at higher risk. We have sought to avoid criteria and thresholds for our service however, and have been able to offer this holistic approach to others not in crisis and who may not have such high immediate needs.

And of course the health services are only a very small part of individuals’ lives. We are touchpoints for some but not all of our community. Last year our website had over 45,000 hits. With the support of the Frome town council we were able to appoint a volunteer co-ordinator who set up a training programme for interested members of our community to become community connectors. These are individuals who know about the resources we have on our website and the health connections service and are able to signpost family, friends and neighbours and those they meet in day-to-day life. Each community connector may have on average 20 conversations each year but with nearly 700 community connectors doing this, it means 14,000 conversations annually.

Having a database of community resources at our fingertips has been a key enabler to different kinds of conversations. Sometimes the preferred solution to a problem might lie within an individual’s existing network of support, so a discussion about the options will enable or precipitate a conversation with loved ones. Where individuals need more support our team of health connectors can work one-to-one with individuals. Sometimes this can be a nudge that allows clinical staff to have structured consultations around what matters, and has led to an exploration of possibilities.

So what have our patients said?

The improvements we have been able to measure tell us that patients experience greater wellbeing, and feel more supported and connected.

Health Connections Mendip 2016/17 statistics

• 81% of (HCM) patients saw an improvement in wellbeing (WEMWBS)
• 83% of patients saw an increase in PAM score (patient activation)
• 93% of patients said they felt more able to access support in the community
• 92% of GP practice staff felt confident that their patients benefit from being signposted to HCM

2017/18 snapshot of patients over a week

• 6% said they have more connections/friends as a consequence of using the service
• 87% said their emotional wellbeing had improved since using the service
• 5% said they felt more connected to the community
• 5% said they fell they have visited the GP less frequently as a result of using the service.

In the three years of a fully embedded model, the Compassionate Frome project has shown year-on-year reductions in the number of patients being admitted as emergencies to hospital.

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). During the same Compassionate Frome – working towards a more connected community COMPASSIONATE FROME 10 © Journal of holistic healthcare ● Volume 15 Issue 3 Autumn 2018 time periods the rest of our community in Somerset has seen an increase of 13,997 emergency admissions (+26.6%) across the patch.

The savings suggest that not only does this way of working improve the quality of care provided, but that it offers us the possibility of a sustainable self-financing new model of care.

We set out to improve care. We wanted to understand each individual’s strengths and weaknesses and adapt the care provided to their needs and priorities. These savings have been achieved by allowing the individual to prioritise what is right for them and by treating each individual as a whole rather than narrowly focusing on what would be the least costly option for a named disease or condition. This is not just the right thing to do but our results suggest it is also more cost-effective, and it has begun to change the kind of the conversations I have in my consultations from being about ‘what are you going to do for me?’ to conversations about ‘ this is what I am planning to do next about my situation’. Patients who might formerly have come with a list of problems hoping to get answers now come with a clearer sense of their priorities and of next steps for improving their lives. As clinicians we have a sense of making a difference to what really matters and with that comes a sense of pride and satisfaction in the work that we do.

There has been a transformation too in the relationships across our local health service. We are now working as one team by building trust and developing strong supportive networks across the different parts of the NHS social care and voluntary sector in our community. We now have a culture of co-operation and pragmatism that comes from a unified goal to do what is right. I feel supported by colleagues in our health connections team, in community services, in social care and voluntary organisations such as Citizens Advice. By nurturing supportive relationships across the wider team, this collaborative working feels safer, more effective and more sustainable.

There has been a great deal of discussion about resilience training to help staff withstand the pressures of rising workloads, rising patient expectations and the blame culture of modern society. Speaking personally, our project has nurtured me and provided a supportive framework that helps me withstand some of the moral distress of working in a service that no longer has the capacity to manage what is expected and needed (Oliver, 2018). It offers hope that the art of my profession can be respected and valued as well as its scientific basis. It is giving us back time to care.

Connectedness helps us all. Together we are stronger, and having our team gives me confidence and energy to continue to try and make a difference. I draw strength from seeing the impact that our project has made on my patients’ lives. In the same way I have felt the impact of belonging to a supportive team with shared values.

We are grateful to Somerset CCG and to the partners of Frome medical practice who have funded this project and allowed it to flourish. With support from Compassionate Communities UK, the model is now being considered in other health communities.

Reference

• Oliver D (2018) Moral distress in hospital doctors. BMJ 360: k1333.