Links Project Report:developing the connections between general practices and their communities

Presentations

Professor Graham Watt

Professor Watt set the scene by reflecting on the successful process of setting up and developing the Links Project, which he considered was as worthy of comment as the actual outcome, as it provided a good example of how general practice and central government can work very well together when conditions are favourable. The project was set up quickly, through local and national relationships and was facilitated locally by strong leadership from two Clinical Leads. The project was comparatively "light" on bureaucracy and was reminiscent of the Scottish Primary Care Collaborative. The project allowed groups of practice staff protected time to meet each other and establish vital connections between and within teams and with others in the community.

The six Glasgow practices were recruited through the GPs at the Deep End, which was formed out of a meeting of the 100 GPs working in the most deprived areas of Scotland. Professor Watt referred to the work of Dr Tudor Hart who has influenced approaches to improving care for people living in deprived areas and described the intrinsic features which capture the essence of general practice:
Contact, Coverage, Continuity, Coordination, Flexibility, Relationships, Trust

Professor Watt reflected on the importance of "connectedness" with a quote from Don Berwick, Head of US Medicare and Medicaid who suggested health practitioners needed to ask, not only "What do I do?" but also "What am I part of?" This was at the heart of the Links Project as practice staff were given a rare opportunity to reflect on their connections with the community. Professor Watt thought local health systems could be less fragmented if general practices made better links not only in community, but with other NHS primary care services, health improvement, out of hours, elective referrals and hospital services. Integrated care depends on multiple relationships, which he described in terms of a wheel with a hub, the hub being NHS general practice, because of its intrinsic features, while the rims are other services, such as Keep Well, services for child health, elderly, mental health, addictions, community care, secondary care, voluntary sector and local communities. Connecting hubs and rims are the spokes, or links - channels of communication needed to make contact. A consistent message from Deep End practices was that these spokes needed to be short, in terms of local, familiar, timely and trusted connections.

Professor Watt described the Social Prescribing workstreams of GPs at the Deep End initiative. Key learning points were that:

• Practices are keen to make use of non-medical community resources, but don't know what is available
• Providing relevant, up to date, local information is a huge challenge
• Practices can't extend their activities, when core activities are under pressure

Professor Watt concluded by acknowledging participants' valuable input into a project which should be further developed.

Dr Peter Cawston - Clinical Lead in Glasgow

Dr Cawston reflected that having health meant having the resources to live and die well which included helping people to find and use resources in the community themselves. Dr Cawston was interested in participating in the Links Project as it represented why he chose to work in general practice in the first place and was reminiscent of his positive experiences of working in communities about ten years ago. At this time, community development work was supported by LHCC's (Local Health and Community Care) and local action groups, many of which were manned by volunteers so that costs were minimal.

Valuable relationships and connections formed during these days had been lost as other pressures were introduced by primary care contracts, which had produced benefits, such as improved management and organisation of long term conditions, but had sacrificed relationships with communities. There is now less time for making connections and developing approaches such as those which were explored in the Links Project.

It was interesting though not surprising that the biggest area for onward referrals in deprived areas was for addictions and mental health. This is another reminder that the problem with living with a long term condition is not just the disease, but the lack of personal, family, community and financial resources to be able to make the best of things. The Links Project provided time for relationship building and the numbers of patients accessing local organisations after signposting was impressive.

However many staff working in primary care feel like hamsters on a wheel because of pressures introduced by the Quality Outcomes Framework. Even if there is a great belief in the value of new work, there is no spare capacity to do anything about it. If people and communities are to be properly supported using person centred approaches, then horizons will have to be simplified.

Dr Sonia Devereux - Clinical Lead in Fife

Dr Devereux described how the 4 Fife practices, with a combined patient population of 34,421, worked with this project to increase links with community resources. Although the Links project had differed from the project proposal originally described, all practices fully engaged with the work, attended all meetings and completed all questionnaires and surveys. The Fife practices acknowledged that they did not have the background experience of the Deep End initiative, which possibly provided the Glasgow practices with a better understanding of the context of the project.

As this was a short term initiative, usually only the lead GP and administrative lead in each practice was involved in data collection and meetings therefore practices experienced some difficulties informing and involving all members of the primary health care team, as it was not appropriate to expect everyone to be familiar with the complex project protocol. Some data gathering tools were thought to be too complex, of limited benefit and represented a lot of effort (in particular the PDSAs); however all practices valued the directory of community resources and reported this as one of the most important outcomes of the work.

Participating practices thought the main aim was to assist clinicians to use sign-posting to link patients and relevant non-medical resources within the community. The use of sign-posting rather than referring patients to these resources was important in order to facilitate patient choice regarding when and whether they wished use the resource recommended. At the start of the project only 24% of staff were confident enough to sign-post patients this increased to 65% at the end of the project. The main factors that influenced the increased staff confidence and knowledge were the awareness and discussions regarding social prescribing, direct contact with staff from community resources and the availability of an up-to-date community resource directory. The initial data collection in Fife identified a broader range of social issues compared to Glasgow, including all the issues identified in the city plus social isolation, obesity, relationship problems etc. Due to this and also the greater geographical area the community resource directories were larger than expected with two practices having over 60 listings.

Each practice worked differently with community groups two practices had "road-show" type events, one practice extended the idea of "speed dating" into "speed knowledge" whereby community groups had 5 minutes to present to the practice team, this meeting evaluated very highly by the practice staff and also the community groups involved.

Dr Devereux concluded by reflecting "sign-posting is not a single step and needs more consultation time" and "you don't know yet what you'll need to know later". An important finding, reported by all practices, was that patients appreciated the "extra" care offered when clinicians shared information about community and web-based resources.

Hilda Davis of COPE (Caring Over People's Emotions)

Hilda introduced her talk by reflecting on Maslow's Hierarchy of Needs and holistic approaches, based on seeing the "whole person" in context of their whole lives. Hilda described challenges to engagement, which included stigma and fear, pride and denial, learning style, awareness and expectation and setting priorities.

Existing healthcare models are still designed around acute, reactive care which does not lend itself to encouraging self care. There is a need to improve the way services are designed and offered. Working in partnership in communities will pay great dividends, especially when local people are involved in the creation of services. Primary care had much to gain by knowing the quality of voluntary sector services and how to refer.

One key challenge for developing local groups are separate funding streams; chasing funds demands time and energy. Another challenge was having to change priorities to match trends, for instance, just as a service is developed and the need established, resources may directed at new priorities. This means more effort may be directed at applying for funds than for developing local responses. Hilda described a pragmatic approach like a fajita - bend and fold the funding to ensure you respond to local need but still fit with funders' priorities.

Hilda also highlighted the benefit of supporting social enterprise. Third sector partnering statutory services can generate income which can be re-invested in service development. Joint working makes sense as general practice and local groups share common objectives.

Peter Ashe - the ALISS project

Peter's presentation addressed the need for practices and community organisations to be able to find information about local support easily, which is the aim of the ALISS project. (Access to Local Information to Support Self Management).⁸ Peter outlined the process of loading directories of resources gathered by the Links practices' into the ALISS Engine. The data was presented by practices in different formats and was edited before being uploaded. Peter demonstrated the easy process of uploading a local asset into the Engine, and showed the value of a shared 'national local index' vis-à-vis individual Practice databases. Peter described an example of community asset-mapping which will inform future data-gathering by general practices. Peter concluded by addressing the 'quality assurance' concern associated with collecting the informal support which people often find useful. He described the user designed 'distributed collaborative curation' for contributions from individuals and a variety of groups who provide support for self-management of long term conditions.