一般財団法人オレンジクロス
日本版「社会的処方」のあり方検討事業（仮題）
第３回委員会資料（2018年10月9日）

Implementation Plan
Dr Julian Abel1

7 key points
1. Implement all the functions of the model
2. Ownership of change must be in primary care NOT TOP
DOWN CHANGE
3. No criteria for identification other than clinical impression– do not use databases
4. Do what is best for the patient
5. ALWAYS use quality improvement methodology forchange
6. EMPLOY A COMMUNITY DEVELOPMENT WORKER
7. Working relationships across teams and organisationalsilos, come first – face to face communication

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Key principles• Build on what is already there• Demonstrate that change is an improvement• Build continuous improvement• Steering group for area is a must
• Think about different ways of delivering key
functions dependent on local preferences• MUST be fully funded• MUST implement all functions of the model• MUST be owned by primary care
• MUST be ground up change3Why is QI so important• Builds system reliability• Engages and enthuses often disenfranchised
health professionals• Puts the power of change into the hands of those
who do the work
• Ensures that a change is an improvement –otherwise don’t do it!
• Deals with complex systems, process, outcomes
and balancing measures• Lead GP in each practice4

IHI Improvement methodology• Relies on ideas generated by the people who do
the work, not top down
• Leadership on the ground• Inclusive in nature• There are no bad ideas, only those that needtesting in small scale testing cycles – adopt, adapt
abandon• Listen to the sceptics – they have useful points• Use of run charts to demonstrate continuousimprovement5

55013000

50012000

Frome emergencyadmissions
Somerset emergency
admissions6

q3 2017

q2 2017

q1 2017

q4 2016

q3 2016

q2 2016

q1 2016

q4 2015

q3 2015

q2 2015

q1 2015

q4 2014

q3 2014600

q 2 2014700

q1 201418000

q4 2013750

q3 201319000

q2 2013800

q1 2013

q3 2017

q2 2017

q1 2017

q4 2016

q3 2016

q2 2016

q1 2016

q4 2015

q3 2015

q2 2015

q1 2015

q4 2014

q3 2014

q 2 2014

q1 2014

q4 2013

q3 2013

q2 2013

q1 2013

Quarterly emergency admissions
Frome and Somerset 2013 - 7

17000

650
16000
15000

14000

Implementation
methodology/mentoring• Each GP surgery has a lead for the practice.
• Coaching/mentoring happens about monthly• Time to implement changes inside practice –includes MDT, training and supporting• Mentoring for community development andnurse time7

Make a Driver Diagram – projectoverview

8Setting up an internal hub in GPsurgery• Identification of those in need of support• Phone call post discharge from hospital• Admin support• Discharge liaison with acute hospitals• MDTs – weekly and monthly

9What is needed for hub – per 10,000• Admin support 0.5 FTE• Nurse practitioner time for phone calls etc. 0.5FTE• GP time for MDT and running project inpractice 0.1 FTE• Discharge liaison

10Goal setting and care planning• Goal setting – My Life Plan, what is importantto me. Health and well being promotion• Care planning – ACP, TEP, DNACPR, admissions
avoidance. Harm reduction• Referral pathways inside GP practice• Visibility and transferability of plans acrossorganisational boundaries• Use of quality improvement
11Who does goal setting and careplanning?
• Health Connectors• Practice staff• GPs• Nurses12

Community development service
4 key functions• Web directory of services• Formation of groups where there are gaps
• One to one work with Health Connectors –motivational interviewing AND community
development• Community Connectors – training and support13

What is needed for a community
development service?
• Community development lead
• About 1 Health Connector for 10,000
population• All help with the 4 activities of the community
development service• Ideally crosses more than one practice –30,000 to 100,000

14Remember that IT serves our needs
not the other way round• Unified database so that everyone can see MyLife Plan
• Ease of use and good coding, important for QIwork• Interoperability of clinical system with My LifePlan
• Ease of use of service directory

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The 3 main outcomes• Improved working lives for clinical teams• Improved patient outcomes• 30% reduction (at least) in hospital
admissions.
• This is clinician led, is not top down and is not
run by healthcare managers. Change must be
led by the people who do the work.
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Funding• Total cost is approximately £10 per head
• Return on investment in terms of emergency
admissions is £60 for every £10 spent• What is the cost of early intervention?
• What we are really trying to achieve iscommunity health.

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Suggested Plan
• Implement a project in a geographical areasurrounding a hospital• Reductions in admissions and costs start
within a year
• Aim for a roll out programme based on thesuccess of the initial project – only after
trends are improving to demonstrateeffectiveness in different settings.
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