Leadership for Personalised Care Case Study: Gillian Pearson - Head of Primary Care Network Development and Partnerships
Background and Context
Gillian is the Head of Primary Care Network (PCN) Development and Partnerships at Taurus Healthcare, a GP federation based in Herefordshire. The federation represents all 19 practices across the county, supporting them to work together to provide more resilient services for the local community. As a federation, they work with practices as ‘one General Practice’ across the county and enjoy economies of scale, while having the flexibility for local GPs to adapt to their community needs. Gillian’s role focuses on personalised care, community development, health inequalities, and relationship building across networks. Gillian hoped that the Leadership for Personalised Care programme would help to develop a ‘single narrative’ across the county and inspire organisations to start working together to deliver on county priorities, rather than as independent organisations. Herefordshire is a rural county with a very high elderly population, which contributes to low levels of health and digital literacy.
The personal impact of the programme
Gillian attended the national programme in 2022 with a team of people from organisations across the, then, CCG. She saw the programme as an opportunity to upskill and widen her knowledge, which was especially valuable for her organisation as personalised care was a core service specification in which they must perform well. Attending with local colleagues was instrumental in developing strong relationships and building an effective team across the county.
‘It gave us time to actually reflect on each of our pressures, learn from one another and build a sense of team.’
For Gillian, the programme was particularly eye-opening as it highlighted that personalised care was central to ‘absolutely everything’ they deliver as an organisation. This ‘lightbulb’ moment sparked a passion for Gillian to ensure that the person is ‘absolutely central’ to how they operate across the federation.
‘So I think for me it's that lightbulb moment of actually, so if we're developing a new pathway, how do we bring in the personalised care element? How are we asking patients what matters to them? How are we delivering it in a way that matters to them? How are we listening to our patient voices to co design things?’
Since participating in the programme, Gillian and her colleagues across the PCNs recognised that they would make more progress on their personalisation journey by working together. Collectively, they became personalised care ‘champions’ for the ICS and established regular monthly meetings for colleagues across the ICB, which she believes ‘changed the conversation’ around personalised care in the system. These meetings were very powerful, as it was the only workstream where providers would come together to collaborate and talk about funding and future planning.
‘It really changed the conversation from the ICB, or CCG at the time, from saying actually “we've got this money and we've decided we're going to spend it that way”, to them coming to us as a group and saying “we've got an opportunity for some funding here, how do we all think we can best use that?”’
Measuring service user confidence
The monthly meetings identified the challenges faced by different parts of the system. The group then worked together to find solutions to move forward. Low levels of health literacy in the community was presenting difficulties when trying to measure ‘Patient Activation’, the group wanted to find a quicker and simpler way of measuring activation that would be more adaptable to meet service user needs. So working with the National Association of Primary Care (NAPC) and the ICB they piloted ‘Simple Activation Questions’ designed to measure patient confidence in self-health management. Patients are asked ‘how would you rate your confidence to manage your own health and wellbeing’, and ‘what one thing do you need to help you improve your health & wellbeing’. These questions were piloted in Social Prescribing, where they were asked at the start of a service user/practitioner conversation.
The pilot analysis showed that the questions were as effective as the most widely used activation measure, ‘PAM,’ and were asked at 83 per cent of interactions during the pilot. On average there was a 1.4 increase in activation score from the first appointment to discharge. They were found to help service-users lead decision making, increase the awareness of their wider needs and support them to have a more active role in the conversation. The questions are now being rolled out across all wellbeing roles and other roles across the ICB.
‘I'd like to think that it becomes common language that every clinician to think of, Right. How confident is that person? Because actually then that enables us to identify what type of role can best support the patient. So if they're quite confident actually they might need just some signposting and we can give them links and leaflets and letters, but if they're less confident, they'll need some more social prescribing time’
Conducting an evaluation of the pilot was invaluable for Gillian, as it provided evidence that she could share across the system to demonstrate the impact of personalised ways of working.
‘You can't beat evaluating and then sharing that as widely as possible’
Creating new job roles
The ICB has funded two Personalised Care Programme Manager roles, based in Worcester and Herefordshire respectively. The roles will work across primary and secondary care to facilitate a single vision across all provider organisations in both counties. Aligning the roles across the county boundaries is a big step forward in collaborative working.
‘I think it’s quite a big step change for us, actually. I think before we've been in competition…. But actually, because we recognise that using the same language and we all understand personalised care at the same level, we know it's the same thing, and that's really exciting.’
The roles will have three main responsibilities:
■ ensure personalised care education is in place across secondary and primary care and that clinicians are delivering against these expectations;
■ look at service specifications for personalised care across the PCN; and
■ bring all wellbeing roles together as a ‘wellbeing team’ that will, hopefully, have a single point of access for service users and in-team referral pathways.
Gillian hopes this will remove duplication, maximise capacity, and empower teams to support patients and whole households with a range of preventative support enabling their independence, providing the right wellbeing service with easy access within communities.
Covid-19 presented a challenge when trying to co-produce services, however, it is something the team are keen to develop further. Most recently, people with lived experience of fibromyalgia and obesity were invited to participate in the development of a new programme of work providing group consultations for wellbeing to patients.
‘Now we've got some patients that are on board with us to help us redesign how we do that going forward. It's a very new way of working for us. Everyone knows that the right thing... And that's a big change for us.’
Gillian and her colleagues across the PCN have made great progress in delivering personalised care to their community, however, there is plenty more work in the pipeline. They are introducing a new case management system for all wellbeing roles across Herefordshire. It will be consistent across PCNs, so data can be better input, managed and shared across the system. This should allow them, not only to better support the service user, but identify any gaps in the support offered by community groups. Collecting this data will allow Gillian and her colleagues to support the community groups by helping them with bid writing to grow and gain funding.
‘So, this is all very new. We're only just starting this, but that's a big change for us. Again, to have that direct conversation then with community groups.’
Gillian is also working to fully strengthen their integration with the wider system. By, for example, creating a shared governance system, bringing people more formally into meetings and sharing plans at the Herefordshire health inequalities group.
‘We're really looking out now to other people to work collectively and from doing that as well, other people come up with opportunities you might not have thought of to link in differently and work in a much more integrated way. …You're not talking about general practice working at scale, you're talking about an integrated primary care network with all the organisations working together.’
For Gillian, she has observed a huge shift in mindset and practice in some areas of the county, with more referrals to wellbeing teams and service-users being better connected with the right support for them. However, in the future, they plan more cultural change work to help the wider system to fully understand and embrace personalisation.
‘More work is needed to really get teams to understand what personalised care means. So really believing it and understanding’
Attending the Leadership for Personalised Care Programme has brought together strengths across organisations in the system to embed personalised care together. The power of shared learning from our system and region has developed networks which remain today. Having the opportunity to hear approaches which have worked well for others from health, social care and voluntary sector, and the expertise of the personalised care team has been invaluable. They brought personalised care to life and shared skills to drive health improvements which enables us to lead change across the system.