Case study: Principia

This case study was developed prior to the NHS Listening Exercise. The outcomes of this exercise have led to some changes to the policy, and this case study may not reflect the current policy position. More information can be found in our detailed response to the NHS Future Forum.

Principia’s approach to partnership working with patients: an integrated care pilot

This case study looks at how patient and public involvement has been key to improve services for patients with long term conditions in one area of Nottinghamshire. Patient representatives worked with Principia to identify areas of duplication and gaps in the system and helped to develop the direction and aims of an integrated care pilot bid. They have been involved at every level of the project and played a key role in informing the service redesign.

Long term condition services for patients in Rushcliffe, Nottinghamshire were perceived to be fragmented, reactive and poorly coordinated across the local health community. There was little emphasis on working with patients to promote prevention, self care and healthy living.

What’s being done?
In order to deliver demonstrable improvements to patients, a number of innovative projects have been set up for Principia patients to access. They include:

  • Met Office Forecast Alert for COPD patients. This provides an automated telephone call when changes in weather conditions and the presence of infections may affect the severity of symptoms. The call prompts patients to keep warm and to check they have sufficient medication. It also allows practices to check on the responses of their own patients and take proactive action if necessary
  • Links with the local Breathe Easy group. This aims to provide help, information and support to those living with lung disease, their friends, family and carers. The group gets involved with a large number of events, as well as inviting speakers to present a huge range of topics
  • Community Clinic for COPD patients providing access to a respiratory consultant on an outpatient basis in the community. Patients are seen by the consultant with the specialist nurse present to provide support and also ensure compliance of treatment and management
  • Urgent Care Support Scheme. Working in partnership with Nottinghamshire County Council, this scheme provides rapid response health and social care for patients to be able to remain at home rather than be admitted in hospital or a social care home when it isn’t clinically indicated or required
  • Well Being Group. This is a wellbeing psychological therapy group for cardio-respiratory patients. Sessions are offered on either a workshop or course arrangement and delivered by mental health practitioners and the local specialist cardio-respiratory nursing team
  • Direct access beds for COPD patients. This sees primary care working with the acute hospital to ensure that patients can directly access beds in a respiratory ward, to ensure they receive appropriate treatment quickly and by health professionals who specialise in their condition

Is it making a difference?
Throughout the pilot project, evaluation techniques and monitoring have been used to demonstrate effectiveness of the individual elements of the overall work. Improvements include:

  • A decrease in the number of unnecessary hospital admissions
  • Development of effective care pathways eg the COPD pathway
  • Community wards in place to support patients with long term conditions
  • Developing the use of the Patients At Risk of Readmission (PARR) tool to identify patients most at risk of admission to hospital and who can be case managed and cared for in a multi-professional way
  • Increased targeting of those at highest risk to provided tailored support
  • Improved patient satisfaction

Partnership working
The pilot has seen partnership working in its true sense across the local healthcare and social care community. Representatives from the following groups have all contributed to the successful implementation of services to  make a demonstrable difference to patients, staff and service users:

  • Patients
  • Principia Patient Reference Group
  • Lay advisors
  • Nottinghamshire County Council
  • Community providers – Nottinghamshire Community Health (now County Health Partnerships)
  • Out Of Hours providers
  • Social care colleagues
  • PCT colleagues – NHS Nottinghamshire County
  • Secondary care – Nottingham University Hospitals
  • Ambulance service – East Midlands Ambulance Service
  • Mental health services – Nottinghamshire Healthcare Trust

Vicky Bailey, Principia’s Chief Operating Officer, says,

“Working with so many of our key partner organisations has meant that the services we now provide for patients with long term conditions are streamlined and more efficient; which ultimately means that the care our patients receive is responsive to their needs.

“The input into our work from local patients and lay advisors means that our services are patient-centred and truly reflect local need.”

How are patients benefiting?
Patients are benefiting in a number of ways, including:

  • Individual care planning, addressing patient needs
  • Improved overall standards of care and increased patient experience
  • Strengthened understanding and role of self-care and carer support in improving patient outcomes
  • Care closer to home in the local community
  • Patients and carers feel more empowered and involved in their care, and more able to contribute to decisions
  • Improved coordination of care
  • Improved primary care team working
  • Reductions in cost to the local NHS of long term conditions so that money can be reinvested into other areas of patient care

Andy Warren, Chair of the Patient Reference Group and member of the Project Board describes the project as

“providing the environment where all health and social care professionals involved in a patient’s care are communicating and working together in an efficient and seamless way. Patients believe this has always happened, though it has not always been the case. Having patients involved at every level of the project has helped to achieve this in reality.”

Next steps
There are plans to continue the work that has been started and extend the partnership working further with mental health and social care. At the same time staff will be looking at the evaluation of the national programme and learning from the evidence presented from it, while continuing with ongoing local evaluation and monitoring of the pilot project.

Patient experience information will be gathered, for example from Patient Diaries, to inform future services and improvements and patient tracking will take place to facilitate early discharge from hospital and ensure patients are cared for appropriately in their own home or community environment.

Finally, best practice will be shared with neighbouring pathfinder clinical commissioning groups to support reduced admissions and save money across the whole county.

Sandra Teece, a member of the Patient Reference Group, says,

“I was invited as a patient / carer representative to sit on the lntegrated Care Pilot from its inception. I have always been listened to and, in many instances, suggestions which l have made to the group have been acted upon.

“To see the pilot evolve has been a very worthwhile experience especially from a patient / carer perspective. Seeing the success and benefit of caring for patients in their own homes, thus avoiding unnecessary and costly hospital admissions is fantastic.”

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