Background
Health 1000 was a new model of care dedicated to addressing the health and social care of patients with complex needs across the London boroughs of Barking and Dagenham, Havering and Redbridge (BHR). It aimed to improve quality of life through personalised care delivered by a clinically-led multidisciplinary team, focusing on prevention and early intervention and supported by contributions from the third sector.
Individuals who were considered eligible for the service were contacted via their registered general practice, and invited to transfer from their current primary care practice to Health 1000. For those who consented, the patient de-registered with their current practice and re-registered with Health 1000.
The Nuffield Trust was commissioned by the Redbridge Clinical Commissioning Groups (CCG) to evaluate this service. We used a mixed methods approach to understand who was using the service and its impact on the use of primary and secondary care services, and on staff and patient experiences.
Methods
We analysed the impact on the use of primary and secondary care services using a case-control design, whereby we matched each of 407 patients registered with Health 1000 to a control who would be registered with another GP in the local area. The specific services we investigated were hospital inpatient visits, attendance at A&E, outpatient appointments and primary care contacts. These were further evaluated at the end of life.
To assess the experiences of patients and staff, we conducted in-depth interviews over two phases. Over the first phase we interviewed 10 patients and seven staff and, over the second, a further 12 patients and seven staff.
All interviews were coded and thematically analysed. We also carried out a survey of a further nine staff employed by Health 1000, and 49 primary care staff working elsewhere within the three boroughs.
Patient registration
Patients were considered eligible for the service if they had complex health needs that were initially defined as five or more of a set of chronic conditions, although these criteria changed over time. The service aimed to recruit 1000 patients within six months, with a view to rolling out the service more broadly across the boroughs in the longer term. However, by the end of May 2017, fewer than half that number had been registered.
Many of the problems with recruitment stemmed from relationships between Health 1000 and other local GPs. Where patients had a long-standing relationship with their GP, it could be difficult to persuade them to move to a new practice. There could also be a reluctance on the part of the GP to lose a patient whose care needs they understood to a service whose value they were less certain about. GPs would also lose practice income.
Implementation of the service
Health 1000 has successfully established a distinct ethos to service provision that contrasts with existing general practice in the area, and is highly valued by patients. Both staff and patients believed that the model marked an important transformation in reshaping patients’ relationship with general practice, something that was an explicit goal of Health 1000. Staff outlined how Health 1000 was providing a service that was “innovative”, “different” and “efficient” for patients.
The majority of patients interviewed were extremely satisfied with the service they were receiving. Patients highlighted the friendly atmosphere, the attentiveness of clinical staff, the availability of GP appointments and the caring nature of the service. This was corroborated by the staff who felt that Health 1000 had improved the quality of care patients were able to access.
Health 1000 patients expressed some dissatisfaction with their previous GP services, again saying that appointments had been too short to cover off multiple conditions, that it was difficult to make an appointment promptly, and that once the need for a treatment was agreed, there could be long delays before it was provided. Other criticisms included rigid processes for obtaining repeat prescriptions, which made medications management difficult and difficulty in getting home visits.
There was a question of whether Health 1000’s registration-based delivery model – also known as a “carve-out” approach – was best suited to the tasks it is trying to perform, or whether a service that allowed individuals to stay registered with their existing GPs would be preferable (the “wrap-around” approach). Opinion about this was very split, with several staff interviewees seeing pros and cons in both types of approach. Some praised the holistic, patient-centred approach to care, while others suggested that money could have been better spent supporting existing practices or community treatment teams.
Some of the challenges with delivering the new service included the lack of a function to issue electronic prescriptions remotely, the distances some staff had to travel to reach patients across three boroughs, and increased bureaucracy when accessing notes for seconded staff dealing with patients outside their “home” borough. Other challenges included integrating with other health and social care services and controlling costs.
Impact on the use of health care resources
After the date of registration with Health 1000, there were no significant differences in use of hospital services between the cases and the matched controls. There were also no differences observed during the last three months of a person’s life. There were significantly more primary care contacts among the Health 1000 patients, although some of this is administrative activity and it is difficult to gauge how much extra work this is in comparison to other practices.
Given the relative infrequency of hospital attendance and the fact that the average follow-up period after registration was 18 months, it is possible that it has been too soon to see a notable impact on the use of hospital services.
Staff had reported reductions in unnecessary outpatient referrals and significant improvements to medicines management. They had also referred to the benefits of better care continuity on resource use, for example in facilitating quicker discharges from hospital and avoiding duplication across the system.
Implications
This study suggests that primary care hubs that are dedicated to the care of older people with complex health needs can have a positive impact on quality of care, and on the experiences of both patients and staff. We have not seen any evidence that these benefits translate into reduced use of hospital services, but, given the timescale of the study and the numbers of patients, it has perhaps been too soon to see any effect. It is also possible that the patient reviews and needs assessments undertaken when they were registered led to identifying new health conditions or needs that, in turn, influenced the use of secondary care services.
Eligibility criteria are intrinsically linked to both the delivery of the service and evaluation. A change in criteria that affects the needs of patients could alter the service being provided. Relaxing criteria may also reduce the marginal benefits of the service. In terms of evaluation, there could be a trade off between consistent, stringent criteria that generates small sample sizes and wider criteria where there is lower risk of an adverse outcome, meaning that individuals would need to be followed up for longer to see an effect.
Success or failure of similar schemes will depend on how well the wider local primary care community shares ownership. Services that do not require patients to be de-registered from their GPs may avoid a number of the recruitment problems, but have fewer of the care continuity benefits. However, this needs to be viewed in the context of a changing primary care landscape and moves towards delivery that is more integrated across sectors.
Key points
- Health 1000 provided a ‘one-stop’ primary care service to older people within three London boroughs who had complex health care needs.
- The service included a multidisciplinary team of health care professionals and specialists who provided proactive patient-centred care.
- The original plans were for a service that catered for 1000 patients, but fewer than half that number were registered over two-and-a-half years.
- Problems with recruitment were mainly due to difficulties engaging with local GPs and persuading them to de-register some of their patients, as well as persuading patients themselves to try out the new service.
- Patients were generally very satisfied with the service, as were the staff.
- Patients liked the friendly atmosphere, the attentiveness of clinical staff, the availability of GP appointments and the caring nature of the service.
- There have been challenges with electronic prescribing, the distance doctors have to travel to see some patients and integrating with other services in the area.
- Staff had reported reductions in unnecessary outpatient referrals and significant improvements to medicines management. They had also referred to the benefits of better care continuity, for example in enabling quicker discharges from hospital and avoiding duplication across the system.
- However, there is no evidence that the service reduced use of hospital services – whether for all patients, those who satisfied the original eligibility criteria, or those at end of life. However, with the numbers of patients and the period of follow up, it may be too soon to detect any such change.