The role of Health Coaches and the Symphony Vanguard Programme in south Somerset
The current healthcare environment in south Somerset mirrors many other counties across the country; with the ongoing challenge to recruit and maintain sufficient numbers of GPs and an extended healthcare team to provide a high quality service to growing numbers of patients. In addition, in Somerset, an ageing population has also created an increased demand on resources as more patients with significant long-term complex health conditions need frequent and specialist healthcare.
The vision behind the Symphony programme is to create a sustainable patient focused healthcare system that can provide patients with the ‘right care ’at ‘the right time’, supported by a joined up system including the NHS, local authorities, the voluntary sector and the communities in which they live. One of the core elements to the Symphony Programme’s success as a vanguard site has been the creation of a new Enhanced Primary Care model (EPC). This has been possible, through a close partnership between GP Practices and Yeovil Hospital. Seventeen GP practices across south Somerset are now operating the model, with over 50 Health Coaches in place across the practices who have seen over 5000 patients to date.
As part of the EPC model, new specialist healthcare roles have been created to focus on prevention, care coordination and patient support. The team of Health Coaches within GP practices build close relationships to help patients and their families to better understand and manage their existing health conditions and to provide practical advice including diet and fitness. They are also able to research information and signpost patients to local community resources and services that can provide support and equipment to maintain a high quality of life at home, often preventing unnecessary admission to hospital. Health Coaches have taken part in skills development training with TPC Health led by Dr Andrew McDowell, which has enabled the team to develop their skills in listening to patients, helping to set goals and developing care plans.
Patients are generally referred into EPC with two or more complex conditions, but each patient is reviewed on an individual basis to agree a suitable personal care plan, treatments and how often they need to be contacted. The practice healthcare teams meet in daily ‘huddles’ where they discuss patient’s conditions, any urgent care or emergency admissions that have taken place overnight and any concerns they may have over missed appointments, or changes in a patient’s behaviour. These meetings have been crucial to quickly identifying when patients need additional, or more specialist treatments and preventing more serious health situations developing.
Under risk stratification, patients are individually reviewed against a scale of 1-10, (10, being the highest and most frequent contact required) based on a number of factors including clinical diagnosis and general health and mental wellbeing, as well as existing levels of support in place at home, such as families and other healthcare organisations.
Hstorically, the GP has been the first and automatic point of contact for patients, but often a patient’s concerns are not clinical and do not need to be answered necessarily by their GP.
GP Steve Edgar explains “In my surgery, the new role has made a huge difference to GPs, patients and their families. The close relationship developed between Health Coach and patient, helps to monitor and manage existing health conditions in a positive way, as often patients feel more comfortable talking to their Health Coach and ‘not bothering a Doctor’ This additional support enables me, to spend more time on the most complex patients and the clinical work that only GPs can do.”
Deborah Neal, Training and Evaluation lead for Symphony Healthcare Services, confirmed “The development of the Health Coach and Key Worker role has been crucial to starting to change the ways in which patients access their healthcare. The Health Coach is part of an extended healthcare team who can support the GP and enable patients to access the right healthcare more easily. Patients enjoy having an easy point of contact and a trusted person who will help to necessary information and coordinate the care services required. GPs are seeing a positive difference in their practices and early indications show a reduction in the frequency and duration of stay for patients within EPC who are admitted to hospital.”
See also blog on NHS England site> https://www.england.nhs.uk/gp/case-studies/symphony-new-model-of-care/