Improving primary care for socially excluded people

1
Improving primary care for socially excluded
people

• Dr. Mark Williamson
• Associate Director of Primary Care, DH
• Senior Medical Adviser Offender Health, DH
• NCL Prison Health IT, CFH
• Chair Secure Environment Group RCGP
• GP HMP Hull and the Quays, Hull

2
My perspective

• Qualified in 1983 passionate about primary care
• Medical school to medical director
• Balint, Pickles, Berger, Tudor Hart, Neighbour,
• Primary care has allowed an Inverse Care Law to
  operate
• Confident primary care is the foundation solution
  for this problem, requires some differentiation
• Pragmatic an argument to take this direction,
  not policy but developing a case
• Presenting a strategic vision
• Social exclusion is an inclusive term

3
Do we need to change?

• June 2007 Health Minister Andy Burnham said
  ...GPs are largely providing a good service, but
  there are still areas where NHS patients cannot
  rely on traditional practices...
• DH - Health Inequalities recognises the need to
  improve access to high quality services.
• Lord Darzi, Next Stage Review improving primary
  care services in deprived areas
• Actually it is an almost universal truth even
  the best exemplars of social exclusion primary
  care could be better.

4
Do we need to change?

• The evidence is poor and disparate always
  recommend more integrated working
• A good proxy Offenders
• Considerable need
• mental health, addiction, sexual health,
  infectious disease, chronic disease, social
  problems, health promotion,
• Poor history of engagement (40-80) with health
  services.
• Integrated care pilots (37) exploring integration
  with social care will generate much learning
• Childrens services, PD services, integrating
  without primary care

5
e.g. homeless people

• 1/3 PCTs no specialist homeless service
• Only half of those with specialist services
  provide permanent registration.
• Current resources could be re-deployed to create
  greater health benefits for the same cost
• Apparent disincentives to individual PCTs to
  provide good primary care for homeless people,
  particularly as they are a mobile population.
• Significantly more likely to have a learning
  disability

6
Questions

• How can PCTs (with local authorities and other
  community partners) most effectively assess the
  scale and nature of the problems in their areas?
  
• How can they best engage people from socially
  excluded groups and relevant advocacy groups in
  developing solutions that will have the biggest
  practical impact?
• What does the evidence suggest are likely to be
  the most effective and cost effective services to
  meet and address local peoples needs?
• CSM

7
The key groups - the vulnerable, socially
excluded, the hard to reach, those suffering
extreme health inequality, including those with
the following problems. Note, all such problems
are made more difficult to cope with by being
young and inexperienced, or elderly and infirm.

• Poor mental health
• Homeless
• Poverty
• Substance and alcohol misuse
• Learning difficulties
• Offenders, in and out of prison
• Violent patients
• Women suffering violence
• Asylum seekers and refugees
• Foreign nationals and non-English speakers
• Ethnic minorities
• Sex-working women
• The children of chaotic and vulnerable adults

• Young people in and leaving the looked after
  system
• People with personality disorders
• People with chaotic lifestyles
• Working late
• Traveller communities
• Rural and remote communities
• People living in deprived and crime damaged
  communities
• Students
• People with chronic diseases
• Those with disability. Severe, (vulnerable) and
  moderate, (tend to be neglected).

8
Population needs

• SUE!

16 of the population (7,808,000) account for a
large proportion of Englands need. Note the
earlier age group for mental health (and drug
misuse).
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... often the same individuals and groups are
affected by a number of conditions...
Disadvantage and inequality are central to our
work and to and any discussion of DHs
customers. These services therefore need to be
predominantly, but not exclusively, designed to
be attractive to the younger age group of those
who are partly skilled or unskilled, and deliver
a range of care pathways.
57 of the population (28,010,000)
10

• Scenario Julie is a 19yr old single woman with
  borderline learning difficulties with a 2year old
  child and who lives in high rise flat on a sink
  estate.
• Her parents are frail suffering from lung cancer
  and mental health problems and she tries to care
  for them.
• She has a moderate addiction to opiates and
  benzodiazepines and drinks cheap cider to excess.
  She is prone to angry outbursts and probably
  suffers chronic depression. She funds her
  addiction by selling some drugs and prostitution.
  
• During the day she spends time with friends who
  have similarly challenged lives and is unable to
  work as she looks after her young child as best
  she can.
• She contracted hepatitis C last year and has
  ulcers on her legs from injecting behaviour in
  the past.
• She has a GP who works in a small partnership of
  two with a receptionist and practice nurse. A
  social worker has been assigned to her but she
  has not heard from them for 5 months which is
  fine by her as she is afraid they might take her
  child away.
• Her housing is very poor and she would like to do
  something about it but the office is somewhere in
  the town centre. The benefits agency is also
  difficult to get to and she is not sure she is
  getting all she is entitled to.
• Though she was referred to the hospital for her
  hepatitis C she missed the appointment when
  intoxicated and has not heard from them since.
• The area substance misuse service wants her to
  have an assessment for starting methadone but she
  hasnt managed to get to an appointment yet.
• She was assaulted yesterday by her boyfriend and
  has a large bruise on her head and she feels
  groggy.
• She doesnt know what to do, she may go to A/E.

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Issues

• Services lack cohesion and integration
• Single issue services
• Navigation of care pathways co-location would
  help
• Behaviours, abilities, mobility, language
• Failure of continuity contributes significantly
  to health inequalities
• Challenging problems need a highly trained and
  motivated workforce
• This requires a differentiation of primary and
  social care services, assuring retention within
  the service, case working and proactive
  intervention for risk.
• Access to specifically tailored, high quality
  services
• Address a range of policy issues
• Reducing re-offending rates, diversion from and
  bridging into CJS
• Requires a review of supporting evidence, build
  on learning from the Integrated Care Pilots (37)
• Leaves untouched high quality traditional general
  practice

12
There are potential synergies to combined
services for several groups with access problems
These groups are likely to have similar problems
accessing primary care services as homeless
people. Each group is reasonably small so could
be manageable within a specialist service.
However, they are unlikely to have similar health
issues
Drug misuse services are in short supply, and a
sizeable proportion will also be homeless.
These may have mental health issues and substance
misuse and a sizeable proportion may be homeless
Ex-offenders may have chaotic lifestyles, have
challenging behaviour and/or be substance
misusers. A sizeable proportion will also be
homeless.
Hard to treat TB patients may have similar needs
for intermediate care beds.
A large proportion of homeless people have
alcohol misuse and/or mental health problems.
However, each of these groups are very large in
size and the majority will be otherwise
mainstream population with few similarities to
homeless people.
Although these groups have some access problems,
they do not have strong similarities or overlaps
to homeless people.
13
Service designs
Most affluent and able
Open Market
Settled, discreet communities
Traditional
Mobile, able, urban
Integrate
Multiple problems, chaotic, vulnerable, less
able, addicted
Co-locate, provide solid floor of primary care,
social care and welfare support
Population need
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Principles

• there should be primary health and social care
  services designed to be more effective to support
  the socially excluded and vulnerable.
• these services should be designed by local
  stakeholders and service users to be responsive
  to the needs and wants of patients and their
  families , responding ,over time, to a changing
  population. Access to the services is on the
  basis of choice.
• to be effective services will need to be
  proactive and incorporate such resources as
  assertive outreach, patient tracking, identified
  support personnel and advocates.
• services should deliver the same or better
  quality of care to the socially excluded as is
  delivered to the population as a whole. This
  should be measured in relation to patient
  outcomes thereby reducing health inequalities.
• continuity of care is a critical issue, morally
  and in respect of delivering effective care.
  Supporting continuity as people navigate health,
  social care and welfare services must be a key
  feature of the configuration and design of
  services.
• in designing these services it will be important
  to identify which specific health care
  interventions/ service functions are required for
  a particular local socially excluded population
  taking in to account the vulnerable groups within
  it.

15
Principles

• the range of services provided will need to be
  appropriate, supported by best available evidence
  and ensure an equivalence of standards of care
  across the country.
• the range of care pathways will span physical,
  psychological and social care and incorporate
  enhanced access to welfare support. Integration
  using shared information systems and co-location
  will be key features.
• service users will experience a coherent and well
  coordinated programme of care and will have the
  support of a named key worker.
• the workforce can be configured in a range of
  different ways and with a range of different
  skill mix, well trained, resourced and supported,
  working within and between, the prison and
  community.
• primary care, social care, and welfare provision,
  will be the foundation of these services,
  delivered by a range of providers, including
  alternative or PCT MS and incorporating enhanced
  service and specialist clinician models.
• adherence to these principles will prove to be
  effective and efficient but that the
  implementation should be as far as possible
  evidenced based.

16
Aims

• To promote the interests of, and benefits for,
  the socially excluded and vulnerable in improving
  access to excellent primary and social care.
• To support the co-location and therefore improved
  effectiveness of primary care and support
  services of social care, housing, benefits and
  employment seeking support, and some secondary
  care.
• To change primary care and social care making it
  easier for vulnerable people to navigate
  effectively.
• To improve access for hard to reach groups.
• Improve the retention in care and treatment
• Improve customer satisfaction.
• To generate increased effectiveness and
  efficiency in urban primary care provision and by
  improving health inequalities to be potentially
  cost saving.
• To enhance the esteem of the workforce and
  promote the expertise in this field.
• To raise the expectations of the population to be
  served.
• To improve health and reduce health inequalities.
• To create a different and more effective model of
  primary and social care delivery where this is
  appropriate to do so.
• To ensure the right people are supported by the
  right team in the right place.

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Increased focus on social exclusion, health
inequality and deprivation
POLICY
Intensive Primary Care
More PCTs and LAs commission these services
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What is the DH role?

• DH has role
• We will deliver best if we
• continue improvements made
• Increase focus on vulnerable or disadvantaged
  groups NHS and social care have not been good
  at responding to their needs.

• No role for DH We will deliver best if we
• Let the NHS decide on local priorities and
  action trust local expertise
• Let system reform work
• use the potential of new regions

This proposal focuses on a number of client
groups and aims to promote a tailored and
coherent primary and social care service model.
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• DH Role is
• Strategic
• Setting direction
• Building capacity
• 4 High level requirements for achieving
• change across diverse and complex systems
• Tell a compelling and consistent story
• Role modelling by leaders
• Supporting structures and processes by devolving
  power and getting right information systems in
  place
• Capability development
• David Behan Oct 2008

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Service design

• Intensive primary care
• Social worker case working where appropriate
• GP and social worker list based, therefore with
  responsibility for those not in front of you
• .and also those from others lists or none, who
  attend seeking help
• Case management and multi-disciplinary
  conferencing for some cases.
• Integrated health and social care pathways, based
  on population health and social care needs
  assessments, in particular providing for
• substance misuse,
• primary and secondary mental health,
• infectious disease,
• sexual health,
• chronic disease.
• Building closer and stable relationships to
  specialist providers providing in reach for key
  pathways e.g mental health, infectious disease,
  leg ulcer management.

21
Service design

• Enhanced continuity, proactive
• Assertive outreach and client tracking
• Translation services,
• Drop in, walk-in, late opening, potentially 24/7
  availability linked to night shelters.
• Secondary care, MH, Inf Dis., GUM, in-reach and
  continuity
• Acting as a credible alternative to accessing
  A/E, minor injuries service?
• Linked primary and social care delivery, with
  housing, employment, education links, and
  benefits.
• Community dental services
• Pharmacy
• Close and determined attention to the qualitative
  aspects of delivering services to hard to reach
  and retain, and challenging clients, that is
  welcoming, with warm and engaging staff with
  particular people skills.

22
Infrastructure

• Local design and development
• Welcoming and non-threatening
• Sufficient and intelligent security approaches.
• Single shared electronic record for primary and
  social care
• Large integrated service provision between
  sectors
• Usually the utilisation of under-utilised
  publicly owned buildings

23
Commissioning

• World class commissioning
• Supported by public health needs assessments and
  linked to JSNA and LAA
• Service specification designed to meet population
  needs, assessed by all sectors.
• A salaried workforce with an effective and well
  joined up inter-statutory organisation local
  management team.
• Variety of funding models and partnering
  arrangements
• Co-location of health, social care and welfare
  support
• Unified bridging services and in reach in to
  prisons, hostels, and isolated communities.
• Plurality of providers, the well-demarcated
  nature of the service arena might attract new
  providers.
• Hard end goals and objectives, e.g. employment
  for a year, housed for a year, drug and alcohol
  free or stable use for a year, achieving normal
  life expectancy, etc.

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Commissioning

• The service and its effectiveness becomes a major
  focus for PCT and LG for primary and social care
  commissioning and delivery
• Neighbourhood renewal funds, supporting people,
  crime and disorder reduction partnerships, local
  best fit.
• Enhance patient/client voice.
• Empowering service users - information on what to
  expect, media reports, advocacy, legal support,
  case workers.
• Performance management, evolved QOF and S.C.
  equivalent.
• Pooled budgets and shared governance
• Quality assurance,
• The service and its effectiveness becomes a main
  focus for PCTs and LAs for primary and social
  care commissioning and delivery.
• Local design and development
• Research - around the overlap of excluded groups
  in deprived areas.

25
Workforce issues

• Leadership role for social workers with GPs and
  senior nurses.
• GPs and Practitioners with a Special interest
  training
• Student professional training
• Use of health trainers
• Practices with a Special interest (NEW) programme
  with support for enhanced workforce
  development.
• Better pension arrangements (cf. psychiatry), to
  attract and retain workforce, enhanced pay,
  excellent administration, IT, infrastructure and
  management.
• Publications to support evolution of brand
  identity and service esteem
• Research within the service to develop
  understanding of this new integrated field.
• Client Advocates

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Costs

• PCT and LA funding issues and allocations 1-2
  variation
• Cost saving from efficient use of infrastructure,
  care pathways, client focused services, and
  improving the impact by clients on their
  neighbourhoods should fund these services.
• Would need collated local programme development
  funding, leadership, and associated analysis and
  academic support funding.
• Many of these services are currently provided but
  are discontinuous with significant client drop
  out, more integration and continuity should be
  more efficient to deliver.
• Incentivise the system for local needs
  assessments, finished care episodes, care
  planning assessments, achieving care objectives,
  patient satisfaction and evaluation of service
  models.
• Incentivise the workforce improved pension
  arrangements, improved links to academia, well
  supported by administration and management
  resources, excellent job planning, and attractive
  contractual and remuneration arrangements.

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Recommendations

• Primary Health Care and Social Care system and
  service differentiation to meet the needs of the
  most deprived and socially excluded is an
  appropriate and supported goal.
• Where appropriate to meet these ends, integrating
  primary care, social care and welfare in to
  services seamlessly commissioned and delivered is
  an agreed approach.
• Initiate a programme involving the following
  coalition to develop the range of policy ideas,
  plan and execute the realisation of this vision.
• Social care
• Primary care
• Offender Health
• Public Health
• Social Exclusion Task Force,
• CLG
• DWP
• Health Inequalities
• RCGP/BMA