As set out in our ICS blog published at the end of last year, Shelford Group members are committed to working with partners to support the health and wellbeing of their communities. In this blog, Policy Fellow Emily Hughes sets out how members are delivering care in the community, and the positive impact this has on patients and population health.
Embracing community-centred care
The Shelford Group comprises ten of the largest research and teaching hospitals in England, with members typically known for providing complex tertiary and highly specialised care in large teaching hospitals. However, with epidemiological trends pointing to a marked increase in long-term conditions and multimorbidity – correlating with an ageing population and widening health inequalities – it will grow increasingly necessary to provide care and support to patients in the community, reversing many hospital-based models of care.
‘Out of hospital’ care underpins the Long-Term Plan’s vision for a 21st century service model, with an emphasis on dissolving barriers along the continuum of care. There are clear and tangible benefits for patients in delivering services closer to home, allowing them to remain more independent, familiar and comfortable with their surroundings, and better placed to support their own health and wellbeing.
Shelford Group members are therefore embracing new models of care and delivering more community services, both directly as community service providers, and in partnership with social care, primary care, and the VSCE sector. These different approaches are all underpinned by an emphasis on collaboration, and a strong focus on person-centred care.
Neighbourhood nursing
Guy’s and St Thomas’ NHS Foundation Trust provides adult community services to the populations of Lambeth and Southwark, which include community nursing, community rehabilitation services, admission avoidance, and early discharge schemes. In 2018, the Trust was the first in England to adopt a scheme which uses key elements of the ‘Buurtzorg’ nursing model. This model of care is led by neighbourhood nurses, who provide patients with more quality care over time, enabling staff to build better relationships with individual patients, and encourage independence and self-supported care. Continuity and person-centredness are key elements of the model, with every patient having a named nurse, and a small number of clinicians who come into their home.
The delivery model blends elements of health and social care, and utilises the wider community support offer – neighbourhood nurses create and share a handbook of local services, to encourage patients to tap into other forms of support as well as nursing, ultimately providing patients with more flexibility and freedom. Patients and families are overwhelmingly positive about this model, valuing the familiar, expert, and friendly source of care they receive from their neighbourhood nurses.
Integrated neighbourhood teams
Another form of neighbourhood model can be found in Manchester, where as part of the Manchester Local Care Organisation, Manchester University NHS Foundation Trust’s health care teams work in partnership with a vast range of health, social care, voluntary and community sector providers. These Integrated Neighbourhood Teams work across 12 neighbourhoods in Greater Manchester, tailoring care and support to local needs.
Teams typically work with people who have one or more long-term conditions, and often therefore have more complex care needs, stretching across traditional service boundaries. Team members are co-located to promote collaboration, and to allow for the joint assessment, planning and delivery of care, underpinned by a multi-agency approach. Not only does this approach allow for more effective care delivery, but it also directly addresses the wider determinants of health – for example, where a district nurse identifies a problem with a patient’s living conditions, this can be raised and addressed with the housing association through a regular multidisciplinary meeting. Evidence shows that social determinants significantly influence our overall health and wellbeing, therefore holistic approaches such as this will have greater impact in supporting local population health.
Multidisciplinary ways of working – rooted in the community – are being increasingly adopted. The Fuller Stocktake, released earlier this year, sets out arguments for Primary Care Networks to evolve into Integrated Neighbourhood ‘teams of teams’, to break down traditional siloes and to promote shared ownership of the health and wellbeing of local communities.
Bringing expertise together
For a growing number of people with multiple or complex care needs, ‘what good looks like’ will stretch across a number of traditional service boundaries; for patients, the less visible these boundaries, the better. Patients increasingly expect relevant information about their care to be shared between different professionals and organisations involved, thereby providing joined-up care in the most effective way.
The advent of Integrated Care Systems in July provides ample opportunity for providers across systems to work together more closely. Increasing the flow of specialist expertise between care boundaries will be key to the success of ICS reforms – Shelford members are committed to this aim, and see real opportunity in accelerating the two-way exchange of knowledge between specialist centres and community and primary care settings. Collaborative pathway redesign for heart failure in North-West London has seen a 50% reduction in ED attendances and increased equality in access, while a South-East London pilot to treat patients in the community through an outpatient parenteral antimicrobial therapy service has saved 563 bed days in three months.
Joining together expertise across systems will address the dual aim of providing more effective and holistic care, as well as placing increased focus on measures to address health inequalities and improve population health and wellbeing. Shelford members will continue working with partners across the continuum of care settings to deliver excellent outcomes for patients and communities.