How it all began…
In 2009, when Hope Citadel first set out to work in areas which had been previously under-doctored, it was very clear that it would take more than a prescription to fix many of the problems encountered by GPs and practice staff in the standard appointment system. A year later, after exploring already established models, the first ‘Focused Care Practitioner’ joined the surgery team at Hill Top Surgery in Oldham, to see if they could find solutions. The aim was to make the invisible patients visible and bring down barriers to universal services.
How does Focused Care work?
Patients are referred by practice staff, local community workers or even the police, when the usual care plan does not appear to be working. The Focused Care Practitioner then works with the patient’s household to begin to unpick situations, assessing need and using local health and community contacts in order to begin to bring stability to an often chaotic situation. They bring together agencies and patients, and also establish accountability for the patient and for the agencies involved, meaning that appointments are attended, practical support is provided and a glimmer of hope and change comes to that household.
Its all about Team
Focused Care works on a team basis, with regular meetings to review cases. Based inhouse and, typically, working 2 days per week per surgery, the Focused Care worker works alongside the practice team to find solutions. All focused care activity is recorded on the surgery clinical system so all staff are aware of the patients current situation. The practice team gets together with the focused care worker to discuss cases every month, this allows the co-ordination of clinical intervention, social intervention and allows creative solutions to emerge. These case discussions are the bedrock of the process through which perceptions of the patient are changed.
It actually WORKS!
Time and again lives have been transformed by the extra care provided by the focused care team, giving support, coping mechanisms and backup for when life gets too much to handle.
Local commissioners have also realised the benefits of the whole person approach. Oldham CCG commissioned the Focused Care model to be piloted in a neighbouring surgeries which was spread to six other surgeries in Oldham
Its time to GROW
In 2012 the Oglesby Charitable Trust was looking for ways to help reduce health inequalities in Greater Manchester, and now with the Shared Health Foundation has championed and supported the set-up of the Focused Care CIC which will steer and support the Focused Care team going forward.
Funding has been provided by the Transformation Fund of Devolution Manchester to roll out the Focused Care Model to multiple other surgeries within Greater Manchester. We currently have 32 workers based in 58 surgeries across Greater Manchester’s most deprived areas with a combined caseload of over 2000 patients in the last 18 months (Autumn 2018). This brings expertise, experience and support to surgery teams, leading to hope and transformation for individuals, households and communities across our city.
If you would like to know more, or enquire about bringing Focused Care to your surgery or area, please click or tap here.