The Community Care Collaborative CIC (CCC) is a social enterprise that is working to redesign the way primary care is delivered in Wrexham. It was set up by Dr Karen Sankey, an experienced GP who came to the realisation that many of the patients she saw daily did not need her medical help. She regularly had days seeing patients without having to take her stethoscope out of her bag. Karen realised that what many patients need is someone to talk to; someone to find out what matters to them. Once this is established the patient can be directed to the most appropriate source of support which often is not the GP.
The Health Foundation estimates that healthcare can only support up to 10% of an individual’s health as the rest is determined by wider social or economic factors which need to be supported by alternative community or social provision. Karen saw this played out daily in her surgery.
Karen realised that a collaborative approach was needed, bringing agencies together to provide more holistic person-centred services. She secured the support of many patients, healthcare professionals, agencies and voluntary and community groups who have together developed a model that provides a non-medical model of primary care which aims to provide for the social, emotional and medical care of its patients at point of need.
CCC was conceived as a way of meeting patient need in a better way but it was also fuelled by the current crises in GP practice and emergency services. Wales is finding it difficult to recruit doctors to GP practices and, combined with many Welsh doctors nearing retirement, increasing numbers of GP practices are finding themselves without GPs. In Wrexham alone at least 7 GP contracts have been handed back to be directly managed by the Health Board due to a lack of GPs willing to deliver General Medical Service contracts (GMS). At the same time increasing numbers of people who are not finding their needs met at their GP, often because they simply cannot get an appointment with one, are presenting at the hospital’s emergency department. It is estimated that 25% of people attending Wrexham Emergency Department could be dealt with somewhere else, with over 30,000 patients a year attending Wrexham Maelor Emergency Department triaged as not being an accident or an emergency and could have been dealt with in the community.
CCC has developed a model of primary care that takes considerable pains to understand and meet the individual needs of patients. Central to the model, Care Navigators work in an asset-based way with patients to empower them to identify what they need and to take control and responsibility for their own care. Care Navigators take time to understand what is important to the patient and provide immediate support or referral to an appropriate service. This may be a doctor’s appointment or referral to another clinical service. In complex medical cases the Care Navigator will refer to a multi-agency Care Coordination team and then work with the patient to implement an individualised care plan. If the issue turns out to be non-medical the Care Navigator will provide support and/or refer on using a social prescribing type model to public, voluntary or community services or activities.
An underlying aim of the model is to ensure that people can access the support that most effectively meets their needs whilst also eliminating unnecessary doctor’s appointments. This will have the result that people’s needs are addressed first visit avoiding repeat visits, fewer doctors will be needed in the practice and the doctors that are there will have more time with each patient or to develop specialisms such as dermatology or mental health.
Another key tool will be the use of CCC’s ‘Everyone in the Room’ model which brings together agencies across all sectors of the community, tapping into existing resources, good practice and community assets. CCC piloted the ‘Everyone in the Room’ model through the Wrexham Community Care Hub project. The Hub brings together agencies such as GP services, mental health and substance misuse services, Job Centre Plus, housing and homeless services. This has enabled homeless people and rough sleepers in Wrexham to access primary care, housing advice and welfare benefits in one room and in an informal, supportive and respectful environment. Having all these services in the room has had a significant impact on both participants and services. It has helped some in participants to reduce or stop their misuse of substances; some have been successfully housed; some have become volunteers; and one is due to start university in September. The model helps service providers work together more effectively, for example having a GP in the room with the Job Centre has reduced time on administration of some benefit claims from weeks to minutes.
More on the CCC website here: https://ccc-wales.org/