While they expected to see that costs were primarily associated with age—with older people experiencing higher costs—they instead found that costs were explained more by the number of chronic comorbidities a patient had.
While this was happening, Yeovil Hospital in South Somerset was thinking about how to improve primary-acute integration to reduce inappropriate acute utilisation. The hospital's leadership team latched onto this study, which helped focus their efforts and resources toward multimorbid patients.
About a year into planning their initiative, NHS England announced funding for new models of care—the Vanguard pilots. The Vanguards are a collection of care model experiments to better manage patients, providers, and costs across the continuum. This was fortuitous timing, and South Somerset applied and won funding as a Primary and Acute Care Systems Vanguard site.
And so in 2014, with Vanguard funding, the Symphony Programme—a partnership between South Somerset's hospital, commissioning group, GP federation, and county council—launched its integrated care pilot to provide multidisciplinary primary care for 1,500 high-risk, multimorbid residents.
Multidisciplinary care hub focuses on prevention
While the Symphony Programme has expanded since its launch to include a variety of initiatives and populations, a key part of their work is their integrated complex care hub.
The complex care team at the hub, led by an extensivist, provides care coordination, senior medical input, and a single personalised care plan that is co-developed with patients. Clinicians in the network include GPs, care coordinators, support staff, specialists, social workers, and a shared group that offers advanced diagnostics and urgent care. The multidisciplinary nature of the team enables each clinician to work at top-of-license.
The model provides patients who have long-term health conditions with the specialist care they need while also focusing on education and prevention. In fact, between visits, patient conditions are remotely monitored through a web platform where the hub team and patients can connect and view the care plan.
Adapting the model
Initially, the Symphony Programme placed the complex care team within the hospital, which caused primary care to lose interest.
In essence, GPs would refer their patients to the hub, which would then completely assume care of the patient. While GPs wanted support for complex patients, they still wanted to be involved in their care, so many simply stopped referring patients to the hub.
In response, within the last six months, Symphony has adjusted the model so that the hub integrates into primary care—each care team sits out with 3-4 practices. Now, GPs remain in charge of their patients, and the complex care team acts as support and wraparound services.
The care provided in the hub has produced great results. From 2014 to 2015 they reduced ED admissions, hospital attendances, and length of stay by double-digit percentages. Looking forward, officials at South Somerset say they embrace ongoing improvement of the model, and hope to continue shaping it around the patient experience.