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

2. Putting it all together The town that gave up medicine

4. 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.

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

6. 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

8. Segmenting based on activation/ Health literacy

9. 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

10. 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

11. 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)

12. 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

13. 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.

14. 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

15. 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).

16. 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

17. So what? What difference does it make?

18. Monthly emergency admissions Somerset 2013 – 2017 –

19. 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.

20. Cost implications of Frome Model
Cost of all admissions Frome in = £5,755,487
Cost all admissions Frome = £4,560,421
Reduction Frome between and = £1,195,066. 
This is a 21% reduction in actual cost between 2013 and 2016
Cost of all admissions Somerset = £86,535,551
Cost of all admissions Somerset  in = £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.

21. 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 complex patients and agree actions, monitoring and interventions. Also review successes, admits and discharges.

22. 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

23. Thank You