How disruptive innovators could lead the way for neighbourhood health

I’m going to make a bold statement: in many specialties, 90% of patients do not need to go to hospital. Our model shows that even complex specialties can be transformed to deliver in community settings. Let me explain.

At SDSmyhealthcare GP Federation in Birmingham, we started our first community service for diabetes in 2017. Already at this time there were elements of people helpfully taking hospital work outside of hospital into a community setting. 

These were mainly consultants coming from hospital to work in practice settings, working with GPs and others to understand complex patients. It was a good ethos but there wasn’t a robust, frequently available alternative to secondary care.

I’ve worked for 25 years in health care and the issue has always been that between primary care and secondary care there is a big gap. 

Once primary care resources are exhausted, the only alternative is for the patient to go to hospital. And, in practice, there’s inherent variation in who goes to hospital. 

This is no criticism of primary care, it is the unavoidable consequence of GP knowledge of over 40 specialities being varied. GPs have 10 minutes with each patient, trying to listen and accurately diagnose in this time, whilst trying to juggle this additional knowledge of specialties. 

Education and upskilling is all good stuff but it’s not really filling that gap robustly and consistently. It’s unrealistic and often out of scope to have in-depth knowledge of all the specialties. 

What’s needed is a high-quality alternative that is a supportive and rapid next step for primary care clinicians. Once they have exhausted their specialty knowledge, they need an option that avoids defaulting to referring to secondary care unnecessarily. 

We brought GPs with extended roles, specialist nurses, pharmacists, social prescribers, and other expertise into our primary care practice. Working together, they enable the practice to provide an alternative next step on a frequently available basis.

We’d review the patient’s case within primary care, reminding and upskilling clinicians through the review process. Where possible we would undertake local diagnostics in our primary care setting as close as possible to a neighbourhood setting. 

We augmented this with brief multidisciplinary team meetings with consultants, to support even more patients locally. Only once that had all been exhausted would we think about going to secondary care. 

The ethos was to deliver a neighbourhood service as an alternative to hospital but not deplete already stretched hospital services, by developing more expert primary care clinicians. We frame these alternative services as Specialist Review Services.

We weren’t just lifting and shifting services from secondary care to the community but creating a different model and pathway.

Our organisation supports over 60 practices and a population of approximately 430,000 people. We have delivered successful Specialist Review Services in multiple areas such as diabetes, renal, musculoskeletal, frailty, epilepsy, urology, respiratory and dermatology specialties. 

Despite lots of collected evidence, the frustrating thing is that a lot of these services have stopped because we only had pilot funding. 

We have consciously shared and worked with other providers to ensure that we replicate this work to increase spread and adoption, so that even more patients benefit. 

While there are many challenges to implementing this more widely, the big one is finance. Right now, funding mechanisms are not optimised to flow to the most impactful parts of the pathway. 

Instead, historical health care funding payment structures make it difficult to support out-of-hospital services. This is no fault of hospitals. They are just as frustrated with having to work within existing constraints. 

I think we’ve got the wrong drivers and policies to incentivise making the right choices for patients. There needs to be a way to commission pathways into the right settings regardless of who is doing it. 

My background is change and transformation. That is what I do and love. But when I moved into primary care it was clear that real world working is very different from theory. You need to get into the reality of it. I lost some of my confidence and skills because I was absorbed in delivery.

We still haven’t got to a point where health improvement is a mainstream way of working. We can do as much as we can, we have the tools in the box and we know where they’re needed, but we still also have to balance the need to deliver. 

I empathise with anyone trying to change systems. It is a lot of hard work. You need to undertake in-depth engagement, communications, small pilots and test and learn. At the same time you need to deliver the day job. So you have to be realistic, somehow making sure you deliver in the here and now while also working to transform services.

There are so many benefits to the Specialist Review Service model. A huge one is reducing costs. We can treat patients in the community at a fraction of the cost of secondary care. 

We’re also delivering care closer to home, doing it in the fastest time possible and reducing variation. It enables clinicians to upskill, adds capacity and builds resilience. And it reduces waiting lists. 

In order to scale quickly, I’d start with diabetes, respiratory, cardiovascular and dermatology specialties. These are all areas that have been successfully treated in primary care and can be developed with GPs being trained through the neighbourhood service to replace the non-complex work that currently needs to be done by a specialist. 

With the support from the Q Exchange programme, we focused on providing Long-Term Condition Multidisciplinary (MDT) support earlier in the patient pathway in a community setting and primary care, avoiding unnecessary hospital attendance. 

In terms of more complex services, we worked on doing this in urology with Q Lab. This was radical and a huge challenge in a specialty that was previously always treated in secondary care settings. 

We got to 90% of patients being treated in the community and patient feedback was very good. Of the first 800 patients supported, 96% were satisfied with the service provided and 100% of patients indicated they would recommend the service to friends and family. Based on this, we’re confident we can do this with most specialties.

What we’ve learnt is that this kind of transformation needs to be co-ordinated and managed at scale, but delivered at a neighbourhood level. 

As a robust alternative, these services need to have high quality clinical care, service management, data collection, tight financial management and robust administration. 

And it must be able to help both sides of the challenge: reducing secondary care referrals and reducing variation in the local community setting.

We’ve run the pilots and we know what’s needed for successful neighbourhood delivery. But we spend a lot of the time speaking to people individually or putting together case studies and still not getting the key messages across to decision makers.

We need to find a set of best practice examples across neighbourhood setting delivery as alternatives to hospital delivery. Then we need to get the right people in a room, do a show and tell of these examples and share what we’ve found, to help be a catalyst for positive change.