Introduction
We are integrating primary care with the voluntary and community sector within Hartlepool to support patients with CoPD to improve their long term health conditions through becoming more physically active.
What happened?
We faciliated a meeting with key staff from Hartlepool Health (the largest PCN in Hartlepool, housing 7 GP surgeries). The attendees included a senior social prescriber, a senior nurse practictioner, the clinical director, Public Health, PFC Trust and Lilyanne's Charity. The aim was to agree a partnership pilot programme that integrates primary care with community services through a focused programme that aims to increase the physical activity levels of paitents with CoPD to ultimately reduce hospital admissions. The project identifies patients through strategic indicators; those who have a respiratory condition and those who may benefit from increasing their physical activity. It looks to change the patient's perspectives on what it means to be physically active, to promote sustained behavioural change, to improve patient's functional abilities, to help them to manage existing condition(s), to reduce the risk of many (other) long term conditions, to help maintain healthy weight, to reduce health inequalities for those living with multiple long-term conditions and to help overcome the barriers they face. The project involves 2 key elemements;
1. Referral of CoPD paitents from the nurse practictioner, GP's and social prescribers to Lilyannes Charity who will deliver 1-1 support including home visits for those that are housebound. This will support them becoming more physically active by delivering activity on prescription resource packs and providing information on community physical activity opportunities.
2. The recruitment and employment of an activity on prescription link worker who is employed by PFC Trust, hosted within the GP surgery and managed by Tess Valley Sport. This role will create a resource pack that will support the delivery of the physical activity to patients with CoPD through a 5 stage approach; chair based exercises to community sport club provision as well as mapping appropriate activity provision for patients.
The ultimate aim of the project is to demonstrate to the PCN the value of physical activity in supporting health conditions and negotiate them using internal funds to sustain the activities on prescription post.
Who was involved?
Hartlepool Health (the largest PCN in Hartlepool housing 7 GP surgeries), a senior social prescriber, a senior nurse practitioner, the clinical director, TVS, Public Health, PFC Trust and Lilyanne's Charity.
When?
The partnerships have taken over a year to develop in terms of building trust, confidence and changing the mindsets of how physical activity can support the work that they do. We secured funding that would support a 6-10 month pilot to be reviewed and impact to be submitted to the PCN for long term funding.
Where?
This allowed for insight to be collected on the needs of primary care as well as shaping programmes and utilising resources to support these needs.
Based in Hartlepool this project involves;
- Being based in a GP surgery
- Home visits
- Community sector activitiy provision visits
- Meetings with a range of partners from primary care, LA, VCS
How?
Trusting relationships were established over a long period as well as our understanding of the area and systems through the place based officer being physically present in Hartlepool, hot desking in various settings, being a key member on a variety of groups and networks. Other key areas of the project were;
- The establishment of the Join the Movement partnership
- The establishement of the Walk into Wellness partnership
- The establishment of the Social Prescriber Wellbeing network
This allowed for insight to be collected on the needs of primary care as well as shaping programmes and utilising resources to support these needs.
Why?
1. Primary Care identified a huge increase in hospital admissions of CoPD paitents.
2. Voluntary and Community Sector identified a huge increase in social isolation and mental health post covid
3. Primary Care starting to understand the value that the VCS can offer in adding value to their services to improve the health of their paitents
4. Lack of connectivity across primary care and the VCS focusing on supporting people to become more physically active - the role of the activity on prescription link worker is vital to achieving this
5. Pilot project needed to demonstrate the value of the VCS to primary care to influence system change and redirect internal funding to support physical activity for people with long term health conditions
So?
1. Improves peoples long term health conditions by becoming physically active.
2. Improves social isolation by supporting people to access community provision.
3. Improves peoples mental health through reducing social isolation and health conditions.
4. Ultimately reduces hospital admissions through reducing patients with CoPD extreme issues.
5. Strengthens the relationship between primary care and the VCS.
6. Provides insight into the way in which primary care functions to enable the VCS to shape delivery to suit.
7. Supports system change within primary care by demonstrating the value of physical activity on patients health conditions.
8. Develops a whole systems approach through the partnership which pools resources, skills and knowledge and demonstrates the value of working together to achieve more for future work
Topics in this article