Recently, Astrid and I attended a conference run by GAVO and TVA entitled ‘Great Expectations – Delivering the Vision for Health & Social Care in Wales’. I felt the title was very fitting. Society is putting our health and social care systems under more and more strain with an increasing ageing population, declining health and high expectations. The constraints the services are under are numerous, some of which link to a dependence on care being delivered in institutional settings and under-using community facilities. Back in 2003, The Review of Health and Social Care in Wales was particularly scathing about the system ‘shifting the burden’. This statement was made in reference to health and social care services, passing the burden to one another when they cannot meet the demand for their own service. In a recent briefing paper, The 2016 Challenge: A vision for
NHS Wales a similar theme was present. The report presented interesting data showing the lack of integration of health and social care. Contributors felt that joint working and integration across the services was one of the main barriers preventing the system from tackling the challenges they face. Both reports clearly indicated that the current system is unsustainable and a proactive rather than reactive service, based on care within the community needs to be adopted. A way in which this may be possible is to re-introduce patch-based teams.
Patch-based teams were common in the 1980s, particularly in the social care sector. Multidisciplinary teams were assigned to geographical patches, mapped out similarly to the current Neighbourhood Care Networks. These teams created relationships with local partners like schools and the police, allowing residents and social workers to be more aware of local services. This method of delivery meant the professionals were trusted and seen as part of the community, therefore they were able to identify and work with vulnerable families more easily.
More recently patch-based teams have been revisited as a potential new delivery model. The model offers personalised care within the community through sustainable methods, potential solutions to the current working constraints and the perceived lack of satisfaction with the NHS and social care sectors by the public.
Modern patch-based working requires collaboration between health care, social care, third sector organisations and registered social landlords. The model is about providing people with the care they need, when they need it and where they need it. It aims to streamline services to become more efficient and sustainable over a longer period, ensuring individuals enjoy a better quality of life over an extended period.
|Potential health and wellbeing hub model for Borehamwood, Hertfordshire|
In 2016/17 North Torfaen has been piloting this rejuvenated delivery model under the North Torfaen Wellbeing Team (NTWBT). In 2017/18 Torfaen County Council are considering expanding their remit to include work around the mental health team supported by the Vanguard methodology, employing a Community Psychiatric Nurse and supporting developing teams. Their users have had positive experiences relating to the change in practice and the model is seen as a resounding success. The team were even recognised in the 2017/18 revenue budget meeting for their professionalism, enthusiasm, motivation and dedication.
Following the success of the pilot, community figures are looking to expand the project to other areas of Gwent and Powys. In order to replicate this success and roll out the new system across Wales there will need to be a number of key changes in current practice and policy.
Initially, the attitude to risk needs to alter. Professionals need to be allowed more freedom to make decisions and be trusted to work in the interest of the local authority, the community and the individuals in their care. Employing the philosophy and process of shared decision making may assist this shift in trust and responsibility. Shared decision making requires partnership within the multidisciplinary teams and their patients. The theory encourages patients and professionals to work together to select appropriate tests, treatments and support packages based on research evidence, professional experience and patient preference. It encourages active engagement for all parties in decisions about options and relies on evidence-based information, shifting the balance of authority and responsibility in the clinician-patient relationship.
|Outcomes of shared decision making practices|
To allow this shift in responsibility legislation and standards will need to be adapted, and the teams initially excused from the restrictions of KPIs. In the short term, the teams will need to understand the influencers of legislation and standards. Professionals will need to be trained to develop insight into these influencers so they can consider them whilst adopting the new way of working. Long term, there will need to be a new framework of legislation and standards. The framework will need to be open, explicit and stable. The legislation will have to be based on the evidence and feedback from the pilot studies and incorporate patients’ views.
Finally, assets will need to be pooled; this includes budgets, knowledge and physical infrastructure such as buildings and vehicles. Ideas versus realities are very different. Organisations may outwardly support the idea of patch-based teams, however, self-interest can sometimes stifle such initiatives. In order to implement the system, all organisations will need to be on board, their views heard and assets considered. Here, an independent facilitator could be useful to ensure unbiased, equal treatment of all parties involved.
So what’s next?
When speaking to attendees at the conference, the ideas, potential resources and willingness to try are evident. The model now needs to be taken forward and the idea sold to those who are able to make the changes happen.