When Chris Little’s emphysema flares up, he no longer has to trek to his local hospital in Birmingham to receive the specialist attention he needs. The 73-year-old retired plasterer can now receive treatment in a modern health centre in the heart of the community, where parking is plentiful and staff are never too busy to offer a word of welcome and a cup of tea.
Little’s wife Sue said he had been “more at ease” since he started attending the East Locality hub, cared for by a team who have come to feel “like a family”.
The new arrangement may have become familiar to the Littles but it represents a radical reworking of the traditional NHS model. Since its foundation almost 77 years ago, the taxpayer-funded health system has generally maintained rigid divisions between hospitals, GP surgeries and community care.
But in the Respiratory Same Day Emergency Care service used by Little, consultant Alain Al Helou sits alongside GP Imtiaz Begum and nurse Hayley Cornelius. Al Helou said that elsewhere in Europe such “polyclinics” are not unusual; in England they represent a striking departure from the traditional hospital-centric model of outpatient care.
As the government prepares to launch a 10-year plan for the NHS next week, the project in east Birmingham points to how Wes Streeting’s often-stated desire to create a health service that is focused on prevention might be achieved.
Streeting told the Financial Times: “I truly believe this model could be the future of the NHS, as we shift healthcare out of hospitals and into the community.”
A key role is played by “integrated neighbourhood teams”, each covering a population of between 30,000 and 50,000, and focused on those who make the greatest demands on both the NHS and social care. The INTs include GPs, mental health and community nurses, social workers and voluntary sector “social prescribers”, recognising that non-clinical factors such as loneliness can be as important as physical illness in driving demand for healthcare.
Rifat Rashid, executive director for Heartlands, the local hospital, and a consultant in respiratory medicine, is one of the main movers behind the collaborative approach. She and her colleagues are “on the brink of achieving a total shift in mindset”, she said. “What we’ve demonstrated in the past 18 months is a willingness to put organisational boundaries behind us.”
But while it offers an encouraging template, health leaders are clear that replicating this approach nationwide will require deep-seated changes. These include universal sharing of records between the NHS and social care, currently far from standard, and new funding arrangements to spur collaboration between different parts of the system.
The merits of cross disciplinary working are on display two floors above the respiratory clinic at the Care Co-ordination Centre, where several large screens track in real time the service’s “high intensity users”. These include the 250 people who account for most visits to the Heartlands’ accident and emergency department.
Whenever one of them arrives at the hospital, an alert is flashed to the neighbourhood team, who will work out if their needs can be met elsewhere. One patient has called the ambulance service 21 times in the last 90 days, and been taken into hospital eight times.
Richard Kirby, chief executive of Birmingham Community Healthcare NHS Foundation Trust, who is in overall charge of the Community Care Collaborative, as the initiative is known, says: “We’re finding it’s often either mental health intervention that people need or . . . interventions from community and voluntary sector-type organisations, more than they need more specialist clinical input to help them cope.”
There was a reduction of about 30 per cent in the number of contacts with GPs after interventions by the integrated neighbourhood teams. The number of “occupied bed days” at Heartlands fell by 14 per cent between June and November last year and December to February this year.
Until the approach can be rolled out more widely, Rashid pointed out, the beds freed up will be all too swiftly filled by patients from elsewhere in the hospital’s catchment area.
Yet disseminating the model may require not only additional resources but a different system of incentives.
Sunaina Khanna, a Solihull GP who has played a leading role in implementing the new approach, said: “We do have to have honest conversations about resource and finances. How is that extra work being funded . . . and where is that money going to come from?”
Kirby hopes Streeting’s plan for the NHS will include the freedom to experiment with a “capitation model”, in which a pot of funding is allocated to each patient in the local population, incentivising the myriad organisations providing health and social care to work together to deliver care as cost effectively as possible.
In east Birmingham, about £5mn of additional funding has been pooled across the area rather than given to individual organisations, such as GPs — a move intended to emphasise the benefits of joint working.
Kirby believes a gradual rebalancing of resources can be achieved so that “the amount we spend on hospitals is growing more slowly than the amount we spend on community and primary care”.
He argues that, albeit on a small scale, the Birmingham project has already provided “proof of concept . . . that you can ‘bend the curve’. Every year more and more people arriving at hospital is not inevitable”.
Matthew Taylor, chief executive of the NHS Confederation, which represents senior health managers, said that not only a capitation model but multiyear funding is “absolutely critical” to change ways of working so fundamentally.
He suggested a key factor in east Birmingham’s success has been securing support from GPs who, in the English system, are often independent contractors. “One of the questions the 10-year plan has to answer is, how do we ensure that primary care, and particularly GPs, come to the table? Because [when] they come together, they really enable change.”
