Proactive and Preventative Models of Care workstream
This workstream aimed to:
- Support and scale approaches to improve access to community led personalised care support in secondary care, leading to more sustainable and integrated pathways
- Develop resources, build the evidence base and communicate the impact of community led approaches in secondary care pathways
Key impacts and achievements
- Supported projects across London to embed community led prevention approaches in specialist pathways, including cardiac pathways and Children & Young People (CYP)
- Showcased and disseminated the impacts of personalised care and preventative approaches in secondary care, welcoming over 150 NHS leaders and staff to a webinar highlighting the impacts and developing 9 case study examples
- Convened a personalised care in secondary care community of practice, which brought together over 80 leaders invested or involved in expanding personalised care into secondary care, to develop resources, find solutions to common barriers and share learnings
- Collaborated with Barts Health NHS Hospital Trust to coproduce and publish a Toolkit, providing guidance around how to embed interventions that take a proactive, personalised approach to non-clinical prevention in secondary care specialist or acute pathways
Why was this work important?
Preventing ill health in local populations is vital for reducing health inequalities, improving population health outcomes and saving time and costs by reducing the resource burden on the NHS.
Social Prescribing (SP) is one example of a personalised, community-based intervention supporting prevention through tackling the wider determinants of health. Patient pathways span both primary and secondary care, therefore enabling community-led, non-clinical prevention like SP in secondary care ensures needs are addressed at every stage in a patient’s journey.
Introducing a whole system approach to prevention, including secondary care, will increase the opportunity to make every contact count and identify people with unmet needs and higher risk factors of disease. It will also be a key enabler of developing Integrated Neighbourhood Teams (INTs) where secondary care is an integral part in delivering equitable care for all.
Partnerships, networks and funding
The Community Led Prevention Team created a platform for all those interested or involved in developing personalised care roles and access to community led prevention initiatives across secondary care settings in London. This Personalised Care in Secondary Care community of practice convened over 80 staff across primary care, secondary care, VCSFE and public health in London. The CoP met between June 2023 to October 2024 to share ideas and brainstorm solutions to key challenges.
The team have worked closely with members of the CoP to plan and deliver a webinar, as well as case studies, illustrating the impact of personalised care roles in secondary care. The team have partnered with Barts Health NHS Trust to support design and implementation of innovative SP initiatives in specialist pathways and to coproduce a Toolkit based on the trust-wide strategic approach to prevention.
Main projects and outputs
Improving access to personalised care in secondary care Community of Practice (CoP)
- A cross-sector network of people in London invested or involved in community led prevention approaches in secondary care
- A platform to champion and support development of integrated & sustainable approaches to improve access to personalized care in secondary care across London
Personalised Care in Secondary Care case study series
- Using Personalised Care roles effectively in secondary care enables proactive targeting of ‘at risk’ groups with inequality in access, experience or outcomes to reduce health inequalities, helping to improve population health and prevention
- There are lots of exciting examples across London where Personalised Care, including Social Prescribing, Care Coordination or Health Coaching are directly impacting secondary care
Personalised care in secondary care London webinar January 2024
- A webinar to showcase where personalised care roles are being used in secondary care to tackle health inequalities in London
- Brought together leaders across London to connect, discuss and enable cross-sector collaboration when exploring next steps for personalised care in London
Secondary Care Prevention Toolkit
- A Toolkit with guidance around how to embed interventions that take a proactive, personalised approach to non-clinical prevention in secondary care specialist or acute pathways
- Developed in collaboration with Barts Health NHS Trust, based on the development of a trust-wide strategic approach to prevention
Community Led Prevention Strategy Guide
- Developed to support ICBs in integrating community-led prevention and social prescribing into their strategy planning for secondary care services
- Includes policy context and drivers, impact and evidence, case study examples, funding models as well as challenges and enablers, and next steps for ICBs
What have been the common challenges?
- Ongoing funding and sustainability of projects, and time-limited pilots
- No contracted requirement for prevention activities in secondary care or Trust wide strategy, therefore the importance of SP and wider community led prevention isn’t prioritised and there’s a lack of support/guidance to get started
- Limited capacity within SP and prevention projects to manage the number of referrals and support all those in need – also limited capacity in community services to accept increased referrals from secondary care
- Lack of protected time for clinical staff to prioritise prevention
- Lack of support for social prescribers and community led prevention approaches are often done in isolation
What have been the key enablers?
- Individual clinicians and clinical teams are motivated to demonstrate the impact of their SP services, are keen to expand their services and tell others about service impact
- In some areas VCSE, primary care and ICBs have been keen partners, supporting INT and working in collaboration with secondary care
- ICB leads and clinical leadership throughout the system who understand the importance of SP data in the wider prevention agenda
- Clinical leadership can advocate and champion community led prevention approaches such as SP in secondary care