Throughout the UK, people are living for longer, but with more complex needs (Centre for Ageing Better, 2019). Consequently, the demand for care has been growing in recent years (Watt et al, 2018). Scotland, like the rest of the UK, is striving to identify the most effective ways to plan and deliver health and social care services that enable people to retain their independence and live well at home for as long as possible.
Policy focus in both Scotland (Scottish Government, 2011) and England (NHS England, 2019) highlights the need for a strong emphasis on more personalised care at home or as close to home as possible. Scotland has undertaken a period of testing and evaluation to identify opportunities to deliver care differently. Interest in designing and delivering services that would meet these needs has led to the development of a programme of work called ‘Neighbourhood Care’, inspired by the Buurtzorg model.
Buurtzorg is a holistic model of community care that was established in the Netherlands to address these challenges and improve outcomes for people (KPMG, 2016). Its principles include:
The Buurtzorg model looks at building independence where possible, whereby the need for future care could be reduced. By focusing on neighbourhoods, it allows small teams to work together to also engage in preventative activities.
In order to encourage innovation in the delivery of person-centred, integrated care, the Scottish Government commissioned the Living Well in Communities (LWiC) Portfolio within Healthcare Improvement Scotland (HIS) in 2016 to support local teams to co-design, test and evaluate models of neighbourhood care inspired by Buurtzorg.
The aim was that these models would also:
Some seven areas were supported to design and implement small, self-organising, geographically based teams of nurses and carers. Each team was tailored for the local context, and aimed to: have the person at the centre of holistic care; support people to make informed choices about their own care; support self-management using a re-ablement approach; and make use of formal and informal networks in local communities to support people to live well in the community for longer.
The local teams have been supported to develop measurement and evaluation plans. A set of common national measures has been co-designed by the seven health and social care organisations participating in the programme and is in further development for future phases of work. The national evaluation explores: how new models of care were implemented locally; the experience of frontline staff; facilitators, barriers and challenges to implementing the model; evidence of impact on the people supported by neighbourhood care teams; and early indicators of the impact on unplanned admissions and length of hospital stay.
A summary of the learning from neighbourhood care across a number of sites in Scotland will be available at HIS's Improvement Hub website (www.ihub.scot) by November 2019.
The experience in Coldstream, Scottish Borders
Buurtzorg founder Jos de Blok's presentation at the 2016 Queen's Nursing Institute Scotland (QNIS) conference prompted the district nursing team in Coldstream to consider how it could apply neighbourhood care principles in its area. The team agreed that the way in which it delivers care needed to change in order for care providers to respond to the needs of an ageing population. In parallel, senior teams from NHS Borders and Scottish Borders Council decided to be part of the national pilot in testing the Neighbourhood Care model.
This provided the district nurse and colleagues from health and social care with an opportunity to shadow Buurtzorg nurses during a visit to the Netherlands in 2017. The visiting team observed many differences in the way in which care was delivered: teams were self-managed (including having control over their budget and education). Both social and health care were delivered by nurses. Recruitment processes were owned by local teams, and teams provided 24-hour care. Lastly, the care needs addressed by the teams were simpler than those often handled by district nursing teams in the UK.
The visiting team also considered whether the model could really work in the Scottish Borders. It inspired the district nurses to challenge their practice and push the boundaries in this direction.
The team in Coldstream covers a population of approximately 3500 people, with some living in remote rural locations. There is just one care provider in this locality, which simplified the opportunities for joint working across local organisations. The district nursing team concentrated its efforts on the changes over which it believed it had the most influence. Each team member's contribution was valued and considered. All decisions about service changes were agreed by the team before implementation.
Working closely with colleagues in social work and care providers, the wider team began to explore how care was provided to people in its community. Together, it came to an understanding that there were a number of people receiving care in their community, whom it divided into three groups:
The team agreed to focus its attention on the third group, individuals receiving care from both the nursing team and the care agency, as care planning conversations for this group of people would require representation from both sectors. The aim was to focus on integrating the care provided in people's houses in order to improve outcomes and reduce unnecessary footfall in people's homes. Enabling these conversations would become the basis of the newly formed multidisciplinary ‘neighbourhood care team’ meetings.
Weekly meetings with nurses, the team manager of the care provider, social workers and allied health professionals enabled discussions about the care needs of those receiving care from both health and social care to be reviewed and about plans agreed. Examples of the outcomes of these meetings include:
This holistic support to care is leading to improvements in health and wellbeing, as demonstrated in the following two case studies.
Case 1: Ruby
Ruby is 88 years old. She has diabetes and requires support from a nurse to administer insulin. She was also visited by a carer, who provided assistance with personal care and meal preparation. The timings of the nurses' and carers' visits were often not ideal, which presented a number of issues, particularly, an increased risk of hypoglycaemia and poor diabetic control. This prompted the nursing team to support the whole care requirement; as a team, it considered care to be whatever the individual required, regardless of whether the support was social care or healthcare.
There were several advantages of this approach to care delivery. Nursing time for Ruby was increased, whereby the nurses got to know her better. The risks to Ruby's health were minimised and continuity of care was improved. The nurses were able to see the whole person and support all of her needs holistically. Lastly, carer time was released, and they could provide care for others who needed it.
Working in partnership with all those who provide support to people receiving care across the community has been an important part of this work. The Neighbourhood Care model has enabled different conversations with colleagues across health and social care and opened up new opportunities associated with the integration of health and social care.
Case 2: Tom
Tom was a successful musician who toured Europe in the 1970s and 1980s. He is now 73 years old and has been dependent on alcohol since 2007. He no longer plays his guitars as his neighbours complain about the noise, and he is socially isolated. Tom paid privately for four detox programmes, which he funded by selling some of his guitars. He would make numerous and frequent phone calls to the out-of-hours service, GP addiction service, nurses and the ambulance service in his area.
In partnership with mental health colleagues, district nurses and GPs, it was decided that a different approach needed to be taken for Tom's care. In May 2018, co-author of this article, Delia Howlett, introduced Tom to Philip, a healthcare support worker with a passion for music. Philip built a positive relationship with Tom and encouraged him to produce lyrics for subsequent visits. Philip supported Tom to play his guitar in the community centre to avoid upsetting his neighbours. Tom's drinking began to decrease as he looked forward to Philip's visits. Daily visits were gradually reduced over time as Tom became more confident and independent. Tom said:
‘The way Philip described his passion for music the first day I met him reminded me how much I had missed it. My problems have never been approached in this way before, and I would hate to lose the support I am receiving.’
Tom has turned to alcohol twice since Philip has been involved in his care. However, data show that he has never needed an ambulance, he no longer makes regular phone calls to the GP practice, and he is generally a more positive person who is regaining his self-confidence.
Changing care delivery
Health and social care integration has been crucial to the development of this new way of working, but integrating care has been more challenging than initially anticipated. Working in partnership involves negotiation and influencing change in the practice of teams to provide a holistic approach. With the Coldstream team, this proved difficult at times when the team had multiple priorities and pressures that were not related to those receiving care using the Neighbourhood Care model. However, the partnership approach developed with the wider Coldstream team demonstrates that it is possible to adopt a more holistic approach to care when multiple agencies are involved. The Buurtzorg model supports self-organisation and self-management. The district nurse team at Coldstream is keen to continue to engage with managers across the locality to explore the opportunity to redefine responsibilities and team structure required in the locality.
One of the main challenges the Coldstream team faced was regarding skill mix. The Coldstream team does not have a uniform skill mix, as is required in a Buurtzorg team. The skill mix reflects the complexities of the patient caseload and is supported by the inclusion of multiple disciplines at weekly neighbourhood care team meetings. Team members are keen to maintain this skill diversity while working further, to:
It has also been challenging to embed a culture in which power and control are decentralised and workers are trusted to organise and motivate themselves. It has been difficult to break down traditional hierarchies, even in a small team. The team still has managers, but the authors do not consider this to be a disadvantage; rather, the situation seems to have the best of both worlds.
Conclusion
By testing this model, it is clear that this new approach to care delivery is making a difference to the lives of the individuals in Coldstream who are receiving health and social care support at home, and to the teams who are delivering this care. Although the first project phase has come to an end (and testing this model was not without its challenges), participating health and social care professionals and the key organisations involved have taken learning from all seven health and social care organisations involved to inform future work. This includes, but is not limited to:
These key learning points are being used to plan the next phase of the programme. It is hoped that by addressing these barriers and enablers of integrated working (while testing similar models of care throughout Scotland), health and social care professionals and national organisations will be able to co-design future models of care that will deliver improvements in the quality of care provided.