Health and social care case studies

How one clinic in Hull cut emergency admissions for frail people by 50% Health nerd quiz question! What common condition increases an individual’s likelihood of attending a GP surgery by over 50%, undergoing emergency care by 216% and adds almost £6 billion pounds to the NHS bill each year? Diabetes? Heart failure? Cancer? It’s actually something that is barely recognised as a medical condition: frailty. So, when a frontline innovation manages to cut emergency admissions for the most severely frail people by 50%, it’s worth paying attention. This outcome was achieved by the Jean Bishop Centre - a unique initiative of the City Health Care Partnership (CHCP), a social enterprise working in Hull, and led by two remarkable physicians: Anna Folwell and Daniel Harman. Anna and Dan will tell you that the key to their success is flipping the usual model of care on its head. The CHCP and its workforce are committed to the idea that it should be the individual who shapes the support they receive rather than the public sector body. As such, their assessment of a person’s needs begins with a very detailed conversation about their experiences, their hopes, their needs. Armed with that understanding, the clinicians and others working at the Centre can work out exactly what is needed to maintain the health and well-being of someone with frailty and their care-givers and provide it in as effective and flexible a way as possible. And that regularly involves bringing in wider community and voluntary sector support from organisations, often located in the Centre themselves, enabling immediate connection to the people looking for help. Pete’s story* Pete’s story is a case in point. A care home resident in his seventies, Pete’s health had worsened significantly in recent weeks. Severely frail with advanced dementia and multiple conditions, he was eating far less, wandering more and at growing risk of falling and hurting himself. The residential home felt it could no longer offer appropriate care. Under normal circumstances, a situation that would often result in an emergency hospital admission followed by a lengthy stay, draining hospital resources and often leading to a further deterioration in the individual’s overall health and well-being. Luckily, Pete was referred to the Jean Bishop Centre. The staff there first undertook a very detailed medical review which resulted in Pete being placed on a more humane and effective regimen. Some of the medications he had accumulated in recent years and which were now doing more harm than good were removed while other underlying conditions that had gone undetected were treated for the first time. Most importantly though, the Centre spoke with Pete and his wife, Joan, in detail about what they really wanted - and the key thing was for Pete to stay in a care home where he felt supported and connected to others. So, working with the Alzheimer's Society in Hull and their own knowledge of the local residential care network, the Centre was able to find a new care home place for Pete while also offering greater support to his wife. The result: a healthier and happier Pete, a relieved Joan and a long hospital stay avoided. Doing with, not doing to Pete’s story exemplifies a spreading approach that seeks to ‘do with’ people rather than ‘do to’ them. Most fundamentally that means doing with the person or family in need of support or care as well as working closely with organisations and people outside the public sector institution, particularly those in the voluntary and community sector. But it also involves senior leaders ‘doing with’ rather than ‘doing to’ frontline professionals by trusting them to make the right decisions both in the radical redesign of a service and in its day-to-day delivery. This is often overlooked when frontline innovations are analysed but ask the City Health Care Partnership what enabled them to develop and deliver such an effective approach at the Jean Bishop Centre and they are clear. As an independent social enterprise, they have been able to break away from the hierarchy and bureaucracy of the mainstream public sector and free up their clinicians and other employees to think for themselves, take risks and focus on impact and outcomes rather than targets and processes imposed from above. A mindset summarised in a phrase one hears a lot at CHCP: “say yes before you say no”. And it’s an approach that has had an impact across the whole of Hull. When it first opened its doors, the Centre set itself the goal of reaching as many of the 3,000 people with severe frailty in Hull as it could. Within two years, it had worked with 90% of that population. That led not only to the 50% reduction in emergency admissions for the most severely frail in that group but also a 10-25% reduction in GP visits for the rest of the group. Work with a wider cohort with less severe frailty has led to  an overall reduction in A&E admissions for people over 80 by 13.6% and for residents in care homes by 18% and reduction in medicine costs of £100 per person per year. The human impact Of course, reduced admissions and innovative ideas are only ultimately tools to achieve the one thing that matters: meaningful improvement in the health and well-being of individuals and their loved ones. An independent evaluation found that the Centre significantly improved the overall wellbeing of older people living with frailty at 2-4 weeks and at 10-14 weeks after the intervention. In contrast, the evaluation control group experienced a decline in well-being over the same time-frame. And you won’t find a clearer example of what a ‘do with’ approach can mean in human terms than taking five minutes to watch this film about Ray. What he needed to massively improve his life was far less complex than Pete - an electric wheelchair and a ramp - but the simple fact that the Jean Bishop Centre really listened to his needs, treated him with respect and then did everything in its power, as quickly as possible, to respond is impactful beyond any quantitative measure. Get ready to shed a tear or two! *Names have been changed in Pete’s story.

How do you encourage some of the most traumatised and disempowered people in the country to access healthcare? The Butterfly Project shows the way How can my team connect and work with the most marginalised people and communities in society? It’s a question that is asked repeatedly within the public sector.  And as we become increasingly aware of how inequality damages health and drives up pressure on public services, it is a question asked with ever greater urgency.  There is perhaps no more marginalised and ignored group than female prisoners. The vast majority have suffered layer upon layer of disempowerment. Many come from poor and excluded communities. Over half have experienced further disempowerment and trauma in the form of domestic violence, sexual violence, and abuse as a child. Then, of course, there is imprisonment itself which is very deliberately a form of marginalisation and disempowerment which has a disproportionately negative impact on women.  The proportion of female prisoners self-harming is seven times higher than male prisoners, while alcoholism and drug use is twice as high. In short, trauma, exclusion and distrust of authority are part of the everyday lives of female prisoners. This is not a group that is likely to engage positively with the state in any of its forms no matter how benign.  So, when a frontline innovation manages not only to engage but generate measurable positive outcomes with female prisoners, it is probably worth the rest of the public sector paying attention.   Releasing the Butterfly  That initiative is The Butterfly Project run by a social enterprise called Spectrum. The Butterfly Project set itself a simple but challenging goal: to increase the cervical screening rate to 90% for the 500 prisoners held at HMP Styal in Cheshire. This was ambitious. The screening rate at the prison was only 64% when the initiative began in 2020. The rate for the English population is not much higher at 69%. So, this would mean encouraging one of the most excluded groups in the country to massively exceed standard screening rates.   The Butterfly Project secured its goal. 92% of women at HMP Styal underwent cervical screening between 2020 and 2022. An achievement that has proved sustainable with a 91% rate by 2024.  So, how did The Butterfly Project do this? There are four key principles to their work. Principles that have wide applicability beyond engagement with prisoners.  1. Go where the people are  It may not sound radical but one major innovation was conducting cervical screenings at the prison itself. Most medical procedures occur outside the prison walls requiring prisoners to be escorted, often in handcuffs and prison vehicles, to a hospital or clinic accompanied by a prison officer. A process that reinforces stigma and inevitably adds considerably to the anxiety of any medical procedure. Conducting screenings in the prison eliminates that barrier.  This goes to the heart of an assumption underpinning much of public sector activity, namely that people should come to us. Vast swathes of the public sector’s work is conducted in buildings and places that suit the public sector rather than the people and communities they are serving. This inevitably creates an immediate barrier for engagement requiring people to invest time and money and to overcome mental and physical health barriers to interact with the public sector. It is telling, for example, that the Community Led Support initiative that has had such a positive impact on social care invests a great amount of time and energy into finding the right venue for their service.  Indeed, the principle has been taken a step further at another prison, HMP Low Newton, where a colposcopy unit has been set up so that any abnormalities identified during screening can be followed-up on site.  2. Let trusted people with relevant lived experience do the engagement  Peer mentors are at the heart of The Butterfly Project. These are prisoners who play a vital role not just in spreading the message about cervical health but also in discussing directly with those who may be anxious or doubtful about undergoing screening.   The mentors bring two vital aspects to the engagement. Firstly, they are far more likely to be a trusted source of advice and connection than a public service professional particularly when the population in question will have all been in conflict with the state and may have suffered mistreatment and discrimination at the hands of the public sector. Secondly, they bring an inherent and profound understanding of the lives of their fellow prisoners because they lead that life themselves.  There is clearly a lesson here for the public sector as a whole. Many public sector organisations assume that public sector staff or elected representatives are the best people to lead engagement. In fact, this assumption should be turned on its head in the case of marginalised groups by understanding that the public servant may well be the worst person to lead engagement. Instead, find those from the community who have the trust and shared experience of the community to act as connectors and conduits.   3. Take time to listen and understand  The role of The Butterfly Project’s peer mentors is not to meet targets or to push people into screening but to listen to their fellow prisoners and understand their fears and hopes. That can take a long time, particularly when working with people dealing with profound trauma. But it is time well spent for it enables trust to be built and allows mentors to develop a deep appreciation of the barriers preventing the women at HMP Styal accessing healthcare.  It’s an approach that extends to the Project’s medical personnel as well, who will often take considerable time to explain the screening procedure alongside the mentors and help address any concerns.  This is not an easy message for much of the public sector to hear. Time is a very scarce resource in a world shaped by constrained finances, rising demand and an obsession with top-down targets. The emphasis too often is on processing people as quickly as possible rather than taking time to listen and understand. But if any public sector body is serious about engaging with excluded individuals and groups, then ways must be found to carve out the time to build the necessary connection and trust.  4. Keep it friendly and welcoming throughout  Finally, and perhaps most obviously, The Butterfly Project places a premium on friendliness and providing care in a welcoming environment. Those who undergo screening often comment on the kindness of the doctors and nurses in the unit at HMP Styal. The necessity of this is obvious, particularly when engaging with people who may have suffered mistreatment and trauma. It is not only the most human approach but clearly it is the best way to ensure ongoing engagement and trust.    What The Butterfly Project teaches us is that with the right practices, enough time and a considerable dose of humility, it is possible to transform engagement with even with the most excluded people and communities. As health inequalities rise and demand pressures keep growing, this is a lesson the public sector needs to learn as quickly as possible.