Writing for The Leaders Council, Yvonne Clarke MBE, co-founder and Managing Director of social enterprise Pathways CIC, discusses the NHS Long Term Plan’s focus on Personalised Care, the advantages that this type of care brings for patients, and what must be done to deliver it.
The Royal College of General Practitioners have sounded out an #SOSforGeneralPractice and put forward an action plan to prevent GP practice staff from burning out, which will also support patients in being able to access the care that they need.
The NHS Long Term Plan confirms the need for transformation within healthcare, including where people have choice and control over the way their care is planned and delivered: Personalised Care. Personalised Care is based on 'what matters' to patients and takes into consideration their individual strengths, needs and expectations.
The Plan aims to ensure that 2.4 million people are given personalised care by 2024, and then aims to double that number within a decade. To support this, the health and social care workforce must have the knowledge, skills and confidence to bring the Personalised Care approach to life. The Personalised Care Institute was formed in 2020 to set the quality standards for Personalised Care.
At Pathways, we passionately believe in the NHS and the difference personalised care can make. We see on a daily basis the difference it makes to patient outcomes.
For example, Mary is a Teaching Assistant and was referred by her GP to the Practice Social Prescriber employed by Pathways, for mental wellbeing support. Upon discussing what mattered to Mary, she was looking for some further support for both her physical and mental health. Since Mary was off sick from work at the time, she confided in the Prescriber that she was suffering from some financial difficulties because she was now unable to cover her rent and bills with the reduced wage.
Mary was also struggling with a bout of Long Covid, and while she had engaged with a Long Covid recovery programme, she was struggling now that had ended in how to go about supporting herself. Mary was concerned about her ability to return to work due to the impact of Long Covid, which was causing her some memory issues. She was worried that she may lose the job that she loved. Mary said that she felt completely exhausted and overwhelmed. Having reflected on her situation, she felt that her mental wellbeing was being impacted by being off sick from a job that she loved, and that the impact of Long Covid was having a detrimental effect on her daily life and fuelling the financial worries that she was now experiencing.
The Social Prescriber and Mary co-produced a plan of action to address these issues. For her physical health, Mary started going on short walks outside, building up distance and time slowly. Having discussed the benefits of 'forest bathing' for mental and physical well-being, Mary starting practising within a local wood. The Social Prescriber supported her with developing her breathing techniques. Given that Mary was still having speech problems and issues forming letters, concentration, and memory, the social prescriber discussed the possibility of pacing activities - even on a 'good day' - so as not to overdo it.
As Mary progressed, she found that she could prepare simple meals. In order to ensure that nutritional content could be reviewed, Mary was asked to complete a seven-day food diary. From the food diary, they were able to discuss a nutritional approach to tackling Long Covid, and Mary was given an information sheet complete with suggestions of nutrient-rich foods to integrate into her current diet.
Mary was also linked up to key human resources advice, so that she could have a productive conversation with her manager and occupational health. Within these discussions, they covered the challenges of Long Covid in the workplace, potential duties on the employer and other aspects including a phased return to work.
Although Mary was struggling with her finances due to her reduced wage; following a review by the Citizens Advice Bureau it was explained to her that she was not eligible to receive benefits. She was subsequently signposted to a local organisation who discussed possible grant options that she may be entitled to. Because of her struggles with Long Covid and Mary’s personal concerns regarding concentration, support was put in place to help her fill out the relevant forms. Mary was made aware of local foodbanks and felt sufficiently confident to reach out to her employer who provided her with some shopping. While she was grateful for the food, this act of kindness made Mary more confident about returning to work.
Over a six-week period, Mary and the Social Prescriber worked collaboratively, which resulted in Mary being able to return to work according to a phased return plan, which left Mary feeling that she was far more able to care for herself.
After her experience, Mary herself commented: “I cannot thank the team enough. During a very difficult time, they have been a beacon of support and help, being consistent and reliable. You are always so positive and encouraging, and I feel like you genuinely care.
“Through this support, I have managed to return to work much sooner than I thought I was capable of. I have already recommended the service to friends who are going through hard times. I feel very lucky to have had the support that I have, and it has definitely built up my resilience knowing you are there to guide and support me”.
The government has committed to recruiting a further 26,000 members of staff into the GP workforce by 2024, including additional new roles such as Care Coordinators, Social Prescribers and Health Coaches. Their roles bring additionality to what General Practice can offer and are key elements of delivering personalised care.
But bringing these new roles in alone, is not enough. Primary Care needs more support to integrate these roles. To integrate these roles needs more than just a good induction, there needs to be co-production across the health and care workforce to remove structural barriers, and Primary Care Networks need the headspace to develop the maturity to embed the roles so that they can make a real difference on the ground.
NHS England have recognised this need and have appointed a network of advisors to support Primary Care.
From what we at Pathways can see, we believe that Primary Care is undoubtedly 'flying the plane, while simultaneously trying to fix it'.
Our role within Pathways is to support the communities that we serve to live happier, healthier lives. So, even though we are a voluntary sector organisation, that does not mean that we do not recognise the challenges that patients face, nor the challenges that our colleagues in Primary Care face on a day-to-day basis.
To this end, in order to support Primary Care, Pathways has established effective recruitment processes for these new roles for Primary Care Networks that want to employ staff directly or where they wish Pathways to act as a host employer.
Additionally, we have developed comprehensive training initiatives for our teams. This training is being certified by the Personalised Care Institute. We have developed processes to support Primary Care in integrating these staff into their teams, and Pathways has recently been appointed as a Primary Care Network Advisor in order to support.
Undoubtedly, the government needs to respond to the SOS. However, I believe as partners to health and care, we all have a role to play - and we need to respond to the SOS too.