Today, we’re speaking to Dr Mike Holmes, a GP in Yorkshire and Chair of Nimbuscare, a local GP-led multi-neighbourhood provider.

Title of paper: Neighbourhood delivery of urgent care in North Yorkshire, UK

Available at: https://bjgp.org/content/76/764/133

Neighbourhood-based urgent care, led by GP Multineighbourhood providers, can reduce reliance on hospitals and NHS 111. Delivering urgent care in community settings is more cost effective than Urgent Treatment Centre and Emergency Departments attendances. Digital integration and shared clinical systems improve safety, responsiveness, and patient experience. Co-locating operational and clinical teams streamlines service delivery and enables operational and quality oversight. Sustained impact requires recurrent funding and performance measures that reflect system-wide improvement rather than single-provider metrics.

Hi and welcome to BJGP Interviews.

I'm Nada Khan and I'm one of the Associate editors of the Journal.

Thanks for listening to this podcast today.

In today's episode, we're speaking to Dr. Mike Holmes.

Mike is a GP in Yorkshire and he's also chair of Nimbus Care, which is a local GP led multi neighbourhood provider here at the BJ gp.

And Mike, who I'm about to speak to, along with Tory Blake and colleagues, have written an article looking at neighborhood delivery of urgent care in North Yorkshire.

So, hi, Mike, it's really lovely to chat to you about this, but before we get into the paper, can you briefly just tell us a bit more about the problem this work was trying to address up in Yorkshire?

Yeah.

So obviously urgent care is a major part of clinical service delivery and what we'd found was that over the last couple of decades that's become increasingly fragmented with multiple providers in the space and maybe a lesser role for general practice as a profession.

And I think as we're moving towards more integrated care and general practice having a prominent role in that, we felt well placed to bid for the delivery of the GP out of hours service.

And I think what we found was that we were able to bring a greater general practice presence and integrate the whole system and make it simpler, easier, more more convenient for patients to navigate around that system.

Unfortunately, I think that had a knock on effect on the.

On the rest of the system, not least the emergency department and I guess

neighborhood teams and neighborhood working.

It's a term we hear a lot, especially at the moment, in policy.

But what do you think about what we actually mean by this in practice and what does it mean for.

For your team up in Yorkshire?

So I think on one level it's about integration and helping multiple stakeholders around the system to work together with shared objectives, trying to make services more accessible to patients and more able to deal with the needs that patients have.

I think from a general practice point of view, I start to think about general practice being much more multidimensional.

So we've got are practices that we know and love, that are functioning units that deliver care to registered lists of patients and hopefully offer continuity and access at that level.

We've got primary care networks where I think the way I think about that is how general practices collaborate together to do things that make sense to be done at that level.

And then we see the introduction of neighbourhoods.

And I think the way I visualize that in my head is that neighborhoods are where different sectors can work together and collaborate to deal with specific cohorts of patients.

And then on top of that we have multi neighbourhood providers, which I think help from a clinical and service delivery perspective, help coordinate care within geographically defined neighborhoods.

And I think we're starting to see how that can be beneficial for patients, beneficial for the system, and use resources in a more of a efficient, effective and sustainable way.

And I think all of that's general practice, actually.

I think that in the modern world, that's all general practice.

Yeah, fair enough.

And we were talking earlier just about Nimbus Care and I was describing it as this GP led, multi neighbourhood provider.

But can you tell us a bit more about it?

What does that actually mean on ground?

Well, Nimbuski has been around for a decade now and it came out of work around federations and working at scale.

And so it emerged out of that sort of thinking where practices would come together to form an organization that could deliver care and coordinate services at scale.

And normally, well, I say normally everywhere is a little bit different, isn't it?

But a scale of around 200,000, 250,000 population plus.

And Nimbus Care started with just a few practices in York coming together and then over the years all of the practices have joined actually.

So we now have all the practices in the City of York working together.

We formed an organization which at the time was a company limited by, shares a very simple corporate structure.

We're now actually moving towards becoming a social enterprise as well, a community interest company.

And we're broadening our footprint to cover the whole of the.

Well, our aim is to cover the whole of the geographical area covered by our local Acute Trust, which is York and Scarborough Acute Trust.

And so it's quite a large geographical area.

It may well get towards half a million patients or more.

And it covers lots of demographic, different types of population.

So we have urban, some urban deprivation, some rural separation and coastal deprivation in that half a million patient footprint.

And I think that's quite exciting because the neighbourhoods are specific geographies within that.

Each neighbourhood will have its own challenges, its own understanding of what patient need is and population health data will help us define that.

And then the multi neighbourhood provider will be able to help neighbourhoods coordinate and hopefully fund the care that they would like to deliver for their population and the specific needs of that population.

And I guess this happens in parallel with the sort of shifts that the government have talked about, you know, a hospital to community treatment to prevention and analog to digital.

And I think all three elements of that are important in the way we construct care in, in, in neighborhoods.

And this paper sits very clearly, I think, in that national neighbourhood policy space.

And you're talking a lot about care for a local population.

And this all started with a local problem, didn't it, that was happening on the ground?

Absolutely.

We, we could see there were issues with the way urgent care was being offered to patients.

You know, there was multiple entry mechanisms, there were multiple, multiple providers all doing different things and potentially struggling with their own internal challenges.

Digitally.

It wasn't joined up.

There were three, at least three different IT systems involved in maybe four actually, if you include the 1, 1, 1 system involved in delivering care.

Staff were confused.

You know, it was quite hard to recruit people to come and work in the services.

And I think Nimbus Care, being inextricably and intimately linked to general practice, being able to take on the GP out of our service, helped us move in a really positive direction.

We started, we used the same IT system, so our practices in your queues, System one.

So we created the out of hours service with a System 1 module and general practice could see the interactions that happened in the out of hours service.

There wasn't the emailing of PDFs describing what had gone on and the challenges around communication with that.

We could see prescribing, we could see history.

It was just safer from a patient perspective and an informational continuity perspective.

The doctors and other clinicians who worked in the service understand it better in that you could see it was being delivered by a GP led provider with links to the practices and therefore they wanted to work in it.

So we managed to, you know, the staff filling of shifts prior to us taking on the service was at around 60%.

So there were many, many shifts going unfilled.

Patients were waiting a long time for callback.

There was an back of work into general practice the following day.

And what we saw when we started delivering it was an instant.

Within a month, our shift fill would have been north of 95%.

We saw those, the waiting times for patients reducing and we saw the handover to work the following day reducing.

Before you go into sort of what happened, I wonder if you can just talk us through a bit about what changed in the GP advour service and why those changes mattered.

So what did your team do here?

Well, I think the changes were we were able to staff the units, we were able to measure demand and staff according to demand.

We were able to manage patients in a single interaction, we were able to request tests, do prescriptions, communicate with their practices.

And, and I think we saw confidence in the service increase.

But fundamentally, you know, the sites from which the service was delivered stayed the same.

We did introduce a clinical assessment service, so we had a triage service that was separate to the sites where patients were being seen face to face.

And I think what we saw there was an increase in the effectiveness and efficiency of that service.

And therefore, you know, that patient experience of ringing 1, 1, 1, then waiting for the out of hours provider to call back became, it felt like the waiting times reduced, the system felt seamless and patient experience was greatly improved and

there were different ways in which people could access the service.

But I think reading the article it seemed that clinic put people straight in.

Is that right or.

Well, there was.

Our paper covers two elements, so it covers the out of hours service.

So patients would access that in the usual way through warm on one.

And what we found was with the length of time they were waiting to be called back, reduced what happened in the first, over the first winter.

So Nimbus Care coordinated that and we ran some hubs around the city where patients could be booked into directly by their GP practice.

So if the GP practice was busy, overwhelmed, didn't have any appointments, they were able to, they were allocated, each practice was allocated some slots in the same day urgent care service and they could directly book into that service.

And again that just felt it was more responsive to patient needs.

General practice felt linked to it and involved in its co design and what we saw was that it was really well utilized.

I think in the York area alone we added in an additional 5,000 appointments over the winter period.

But it felt like GP owned them as well.

You know, they felt like our appointments.

And so I guess that's the essence of integration, where you got multiple elements of the system all feeling shared ownership of an additional service.

And I think that's one of the things that we're quite proud of.

You know, we're, you know, we work very closely to our member practices, we involve them in the design of these services and it seems to narrow the gap between in hours general practice and out of hours general practice.

Yeah.

And I think, as you were describing that digital integration and sometimes co location came through quite strongly.

And I wonder what your thoughts are on why those were such important enablers in this system.

Well, I think we hear quite a lot about fragmentation and siloed working and I think whilst that definitely confuses patients, I think it also distances general practice from those services.

So we worked very hard to remove the siloed working and that just a lot of that is around communication with practices, it's around building relationships not just with general practice, but with our hospital colleagues and our ambulance service colleagues.

And I think that's, you know, as we boil this down, I think those relationships within a system are really, really important if we're going to improve the way we deliver services and if we want to improve patient experience.

And I think sometimes there are some of the things that are overlooked when we measure success.

I think when we look at urgent and emergency care, we seem to focus on, you know, hospital centric metrics, which I'm not sure they've fully capture the innovation and progress that's made in the way we deliver these services.

You know, a lot of it is about integration.

It's around relationships, it's around patient experience, they're the things that really matter.

And I think sometimes we get distracted by focusing on things like a four hour target.

And actually, in our work in the paper, what you'll see is that despite all the improvements we made, and the list of those improvements is significant in terms of fewer ED referrals, fewer hospital admissions, a reduction in urgent treatment center attendances by 25,000 patients, the metrics, the four hour target doesn't measure that because the four hour target or performance against four hour targeted red did really change.

But what we saw is a significant case mix change in that the ED was dealing with more complex, sicker patients, which is quite right.

That's what they should be doing.

But of course they're more difficult to manage and take longer to manage.

And one thing that I thought was really interesting was that the use of those same day urgent care appointments was really high.

And I wonder what you thought that tells us about unmet need in general practice at the moment, or at least in the practices that were in this.

In this patch.

Yeah, I mean, it clearly tells us something's going on there, doesn't it?

I think, I suspect it reflects workload in general practice.

It might reflect some patient dissatisfaction that they can't access their practices in the Way they would like to tells us they want to access their practice but are having to go or feel they have to go elsewhere.

You know, when we ran those same day urgent care clinics, we actually saw a reduction in 1, 11 calls, reduction in ED attendances, a reduction in UTC attendance.

So I think what it tells us is that patients want to access their general practice for urgent care, but they can't or they haven't been able to.

And during this period they were able to.

And actually, if you think about that and reflect on that, general practice is we're the experts in urgent care in same day urgent care and the system had been designed so that that care was being asked of the non experts, that is the emergency departments, they're not the experts in same day urgent care.

I think that's probably, you know, if we tease out what the real findings were here rather than looking at the metrics alone, I think that's probably a good place to start with that.

I think what we saw were patients being able to access care in the way they would choose, more convenient closer to home with a system they know and are familiar with.

Are you general practice?

If a PCN or ICB wanted to replicate this, what do you think are the absolute non negotiables?

And I mean, what I'm trying to get down to is what do you think really made this model workable?

Yeah, I think, I think you have to have structure, so you have to have a system where general practice is working together and has a mechanism to do work together.

I think relationships, I keep saying relationships, but I do think they're really important.

And recognition that same day urgent care is the domain of general practice.

I think funding has to move, has to be focused in the right place.

And I think having the GP out of hours service run by the GP provider is probably really important.

You know, our system before had a provider that wasn't based in our city.

They had their own challenges in their own objectives and it didn't work.

I think if we're really honest, it wasn't working.

General practice wasn't bought into it, shifts weren't filled, patients weren't getting the experience they wanted.

Money didn't seem to be being used effectively and appropriately and it needed to change.

I think digital integration is really important.

I think, you know, I understand some of the theory around plurality of provision and having different systems that compete with each other and drive quality, but actually if we're really focused on patient care and patient experience, having a single system that all the data is on Albeit modules being run by different organizations does make a difference.

I think we've seen categorically that that's the case.

And given the increasing policy shift into community based care and this consistent sort of message around increasing neighborhood teamworking, if you want to send one lesson to policymakers to take away from this work, what do you think it should be?

So I think we hear a lot of rhetoric about this shift from hospital to community and we've been hearing about it for decades.

Well, certainly at least the last two decades.

And what we don't see is a material shift.

So I would like this time to be different.

And I think having local organizations or local mechanisms for organizations to work together is key.

I think we have to invest in it, so we have to find ways of leveraging this funding shift to make it happen.

I think every, what I've noticed is that every area is different, every city is different, even every neighborhood is different with different needs.

So I think we have to somehow find a way to have some principles of how we're going to do this.

But the detail of how it is done in every system needs to be entrusted to those who are delivering it.

So we have to see some seeding of autonomy of design to providers.

I think we have to have some flexibility in the way that things are contracted.

For sure there'll be some core things, but there needs to be some flexibility of what else is involved because every patient population will have different needs.

Data is going to be important.

I think understanding population needs requires some population health data and probably some sharing of data between organizations.

That's one of the things that we've been able to do with our member practices, is have data sharing agreements that we can use to shape the care that we deliver.

So it's going to be an interesting journey.

We're going to have to evolve and learn as we go.

But what I'd like to see is a real determination to make this happen this time.

Something that we perhaps haven't seen historically.

And I think collaboration within general practice is also going to be really important.

We have to work well together and in a coordinated way together in order to make this happen.

And that's not easy.

You know, I've been living and breathing this for the last, well, probably the last 20 years.

And it's not been easy.

But I think now we've got the political environment is right for that.

I think we can start to see the benefits and share the benefits of what happens when you do work like that.

And I think it actually strengthens and increases the case for these different layers.

We need a really highly functioning, strong general practice supported by good GMS contracts that allow that to flourish.

We need a way to find to support working together at PCN level between practices and at neighbourhood level.

And we need an area that coordinates that.

I think defining your neighbourhoods being really clear that the neighbourhood geographies work for general practice, they work for the local authority and they work for the other stakeholders in the system is important and I think once you've got those building blocks, it becomes easy to see how neighbourhood care can work on a practical level.

And it's a really fascinating article, Mike.

And again, I just really want to congratulate you and Tori for publishing this as the first innovation article in the bjgp.

And I just, yeah, really highly recommend anyone listening who's interested in this and I think it's something that's hugely topical and relevant to everyone working in general practice to go back and have a read of it and see what they can pull from it really in terms of lessons for their own patches.

Really.

Yeah.

Thanks.

Nada.

I mean, I think I'd like to extend a thing thanks back to the bjjp, actually.

I know this is a new section of the journal, but I think it's really timely.

I think there's so many good examples of this way of working around the country.

You know, I've been fortunate to meet many people who are working in federations that are becoming multi neighbourhood providers and I think they're doing some amazing work and I think having a, a section of the BJGP where this work can be highlighted and shared and built is really, really positive and very, very much needed.

So thank you.

Yeah, absolutely.

And hopefully that's a plug for other people listening who've got some innovative ideas and practice to submit their examples to us as well.

So, yeah, yeah, thank you.

And while we're on the word on the, on the, on the subject of thank yous, I think, you know, I, I chair Nimbus can.

I'm involved in sort of overseeing much of this work.

But the teams on the ground, Tori and her teams and the other team, key clinicians in Nimbus Care working on other projects.

I think there's a lot of people involved in delivering these services and they're doing a phenomenal job and it's not easy.

They have to be a little bit courageous at times and it's very, very much appreciated.

Brilliant.

Thanks very much, Mike.

It's been great talking to you about this.

So, yeah, thank you again for your time here.

Pleasure and thank you all very much for your time here and for listening to this BJTP podcast.

Tori and Mike's Innovation article can be found on bjgp.org and the show notes and podcast audio can be found@bjgplife.com it's been great to talk through this Innovation piece with Mike and yeah, I hope that you will go back and read the article in full on the BJGB website or in the March issue.

Thanks again for listening and bye.