A unique offering for patients with highly complex needs | Peter Tinson

SAVE ITEM
carer and older woman

Many over-60s have multiple conditions and highly complex health needs. To better support them, the Fylde Coast local health economy has developed an innovative new care model that takes a more holistic approach to their care and helps to keep them out of hospital.

This model, the extensivist care model, is based within the Fylde Coast Vanguard, a multispecialty community provider. Launched in 2015, the success of the model has seen it rolled out across the Fylde Coast.


The Fylde Coast vanguard caters to two different but equally disadvantaged populations: one living in Blackpool amid deprivation and very poor life expectancy, and one in the surrounding rural towns and villages facing problems associated with old age, including multiple long-term conditions.

The vanguard developed an extensivist service to help meet these particular population needs, using resources as efficiently and effectively as possible. It is a unique offering for patients with highly complex needs, with a truly multidisciplinary approach to patient care. It provides a quality clinical service while coordinating the overall care pathway, including linking in with social services if needed. 

Extensivist care is aimed at people aged 60 and above who have two or more long-term conditions, such as diabetes or chronic heart problems. The service sees senior consultants, GPs, advanced practitioners, care coordinators, wellbeing support workers and other supporting staff all working together as part of one harmonised team. 

Patients are referred by their GP and meet with the team to undergo an initial assessment from which a care plan is developed with them. Each patient is allocated their own wellbeing support worker who they meet with on a regular basis to progress this care plan and achieve the small but personal goals they have set themselves. Crucially, the service provides a single point of access for patients.

The service operates from four community-based ‘hubs’ that serve all ten local neighbourhoods, with every GP practice across the area able to refer eligible patients.

Feedback so far is that patients love it and staff believe that what they are doing is important for their patients and their families. Huge differences are being made to patients’ lives just from making simple changes. Even with the most sick, most complex patients, the contact with wellbeing support workers and care coordinators is what makes the most impact for many patients.

The figures are bearing this out too. Since February 2017, evidence shows that from the group of patients referred into the extensivist service, there has been a 14 per cent reduction in A&E attendances, a 23 per cent reduction in non-elective admissions and 18 per cent reduction in elective admissions. This new model of care isn’t just about creating sustainable services – it is about transforming patient experiences too.

Friends and Family Test results show that 99 per cent of patients would recommend the service, and the following comments underline the hugely positive impact the service is having on patient experiences:

  • “My health and wellbeing have improved massively. I can only thank everyone for their help and support.”
  • “It’s like you’re knocking down brick walls I couldn’t get through.”
  • “Would certainly recommend to other people like me. I feel more confident in myself. I’m living life like I used to.”
  • “I think it’s wonderful. Makes me feel safe. It makes me feel so cared for.”
  • “The support and help given has been a credit to the NHS.”
As with any new model of care, there has been lots to learn along the way, ranging from new system leadership behaviours to practical implementation lessons, such as the importance of promoting the service to patients. 

As we move beyond the vanguards and into the era of sustainability and transformation partnerships (STP), it is important to retain an environment where we can continue to test and learn from new ways of working, while being given the freedom to inject our collective learning back into healthcare. 

Peter Tinson is the chief operating officer at NHS Fylde and Wyre Clinical Commissioning Group and the senior responsible officer for the Fylde Coast Vanguard. Follow the vanguard on Twitter @YCOPFyldeCoast.  

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