I have in the last few days read so much comment and had so many discussions with people about the three by-election results (as preparation for writing this post – and about the Oppenheimer film (because of my book of the same name), that I have begun to muddle the two in my mind.
Remind me – which one was about our collective survival in the face of intransigence and stupidity?
I also found I have little new to say about an event where everyone has something to be pleased about – as a LiberaI, I was delighted by the result in Somerton and Frome. So I thought I would write about the sheer imagination of people who live there, certainly in Frome.
There is the independent town council, which is determined to push the boundaries of what might be possible at this level of government.
When I was there, a few years back, there was a local T-shirt with the slogan, in typical dry English humour, proclaiming, “Let’s make Frome shit again!” This is a place with innovation in the air.
I had gone there with my friend and colleague Professor Becky Malby, to help her write a report (see pp 42-44) for London South Bank University about their innovative approach to social prescribing in the new NHS centre where they share the premises with a range of other local charities and projects.
So what is it about Frome that makes this possible here? One success factor has to be the huge modern surgery building, built by PFI and including two practices, district nurses, dementia support and all the panoply of the modern primary care, opened in 2013. With 30,000 patients, they are big enough to make a difference – yet paradoxically, covering only ten per cent of the population of Somerset, they are also small enough to innovate.
I was most excited by their approach to what I would call co-production.
Picture this, for example. A ‘health connector’, an employee of the Frome Medical Centre, finds a man on a park bench in Glastonbury and they get chatting. He has been drinking. In what other community apart from Frome would the man on the bench be signed up and trained as a community connector?
But then, as says Jenny Hartnoll, he talks to a lot of people there. “Can you think of a better way of reaching the ‘hard-to-reach’ people than by training key people in the community?” she says.
“I knew people would say ‘is it safe?” But what isn’t safe about it? People talking to each other and letting each other know about now to access support and get involved in their community.”
His training only took twenty minutes or so giving him what he needed to get help – this isn’t the approved nine-hour training for official ‘health champions’. It is a sign that this is an ambitious programme, not just of patient volunteering but also service integration, that has all the hallmarks of success: it reflects the innovative personalities behind it – Jenny and her line manager, Dr Helen Kingston.
Jenny describes this as a sense of trust. She is trusted by Helen and, in turn she trusts her staff to innovate on park benches or wherever they happen to be. Also, after some effort, the local social care team trusts the medical team enough to join in with weekly meetings of the ‘hub’ to discuss vulnerable cases – and to share each other’s records.
Trust is the key, and that is a scarce resource in the modern NHS. Yet Health Connections Mendip by then covered 11 practices, with a population of 115,000 and employed 12 workers.
The team’s remit was to understand what mattered to the individual in front of them and to do what was best for that individual. Following human instinct rather than protocol and seeing the human being in front of them, this was invariably the right course of action.
So, when they began – along with the opening of the new health centre in front of the hospital in 2013 – she sat in cafés reading noticeboards, talking to everyone, to get the information she needed to build up some kind of social prescribing guide book for the website.
When I was there, they had 400 groups and services – 2,000 was too much, as it turned out, and just confused people. The site got 73,700 hits last year. Not that they rely on the Internet – they have five talking cafes a week, a manned phone line and a monthly local radio slot.
Where there were obvious gaps, Jenny was able to set her small group of professional health connectors to start groups to fill them. They also do on-to-one interviews with patients, starting the conversation – as it so often does in co-production – with asking not what they need, but what they want in life.
They are supported by nearly 1,200 ‘community connectors’, trained as volunteers across the Mendip district, navigating people where they need to go. Or presiding over the talking cafés. Jenny calculates that, if all the community connectors have twenty conversations a year that amounts to reaching out to 23,000 people every twelve months. This community movement has far greater reach and scope than a small number of paid employees could ever achieve on their own.
Health Connections Mendip is part of a highly ambitious Frome Model of Enhanced Primary Care – aka Compassionate Frome – that also manages to co-ordinate across health and social care, and meets in the ‘Hub’ at the health centre to go through each other’s databases to see who needs a visit and who needs other kinds of support.
It also works. They reckon that the number of emergency admissions to hospital among Frome patients has gone down by 16 per cent, which they rose by 30 per cent during the same three-year period.
The figures are disputed by the local CCG – since the hospitals are still full, it implies that success of Frome has created spare capacity, which is simply taken up by others. But they accept that there has been an impact.
The point here is underlined, as it so often is, by medical research into the importance of face-to-face relationships.
“The absence of social relations are more effective than anything else at reducing length of life and wellbeing,” says Dr Julian Abel. “They are fundamental to our health. If this was a tablet, it would be an absolute medical miracle. Empirical science has developed ignoring emotions, and it is an enormous blind spot, because we can’t measure them.” (See Pinker (2015), The Village Effect).“It also changes it into health and well-being centre,” says Karen, the practice manager. “The building is always busy full of support groups. When you walk in, it’s like a mixed environment. You might find people sitting in the café, eating cake.”
There are some other peculiarities that might go some way to explaining its success.
My life plan. The health connectors start their interviews with patients in co-production style with the question ‘what’s important to you?’ This forms the basis of a ‘my life plan’ for everyone, which sets out a scheme that covers every aspect of their lives from medical to social.
The mix of professional and volunteer staff. They then employed 5.5 health connectors to cover the 115,000 population. They might be clinically trained, but “it was more important to get the right kind of people,” says Jenny. They now also tend to employ people with experience of motivational interviewing. “We can just get on with it, because we have a staff member,” she says.
Nobody has to wait for permission to start, for example, a pet therapy scheme (30 dogs awaiting assessment for going into people’s homes).
Building on what is there already. The health connectors are the catalysts that have encouraged the emergence of self-help groups to fill the gaps – including those covering people suffering from leg ulcers, COPD, macular degeneration, ME, MS, strokes, dementia, and damaged hearing. One patient recently asked if he could start a metal-detecting group. They go where the energy is.
No criteria other than clinical impressions. They shun sophisticated data to help them identify the right groups of patients who would benefit the most from some kind of intervention. They use their impressions of the people they see face-to-face.
Doing the best for the patient. In the same way, they are skeptical of compliance or KPIs as a motivation for action. They commit to doing whatever is best for the patient before them. The Frome system doesn’t have to fit into organisational diagrams. “We are much more fluid than diagrams suggest,” says Jenny.
When I was there, we sat in on a presentation the same team gives various visiting commissioners and health officials from other parts of the UK. It gave us something of an insight into why this is difficult to organise everywhere. “We have been talking about this for four years,” says one group from an urban area. “We are now utterly fed up with talking…”
Judging by the website, the community connectors have since morphed into ‘green community connectors’ in a joint project between Edventure Frome, Frome Medical Practice and Frome Town Council and are funded by The National Lottery’s Climate Action Fund.
Is this at all relevant to the by-election? Well, it could be – if the Lib Dems have the sense to listen and learn from the people they now represent.
