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The Brighton and Hove Proactive Care Service connects GP surgeries and other organisations across the city to empower people to manage their own care. We provide the development support for this new model of care on behalf of GP practices and other organisations in Brighton and Hove.

It is a three year, city-wide programme commissioned by the CCG. It is an approach that at its heart moves the system away from asking ‘what’s the matter with you?’ to ‘what matters to you?’

In collaboration with colleagues across the system, Here has led the process of bringing clusters of GPs together to realise the vision that people who are at risk of losing their independence are helped in ways that really matter to them before this happens.

Guided conversations and data analysis

Key to achieving this is the ‘guided conversation’ – a conversation carried out by an Age UK (Brighton and Hove) care coach. This creates unique and individual ‘I’ statements, which are at the core of how the system then interacts with that individual.

Also important is the use of data to understand patterns to assess the likelihood of a person being admitted to hospital.

Building trust and information sharing

It is key that we use an approach to selecting patients that is person-shaped rather than service-shaped. This means that we select patients based on their actual demands and risk rather than the typical approach to select the patients in the front of the GPs mind. Through proactive care information sharing has been essential and the need for information about people from different systems such as adult social care and housing has been apparent. The challenge is maintaining the trust of the public whilst gaining access to information we can use to support people in their lives.

So far we have learned:

  • We need to build stronger and broader alliances across the range of professions and sectors that impact on people’s lives – and we have begun to do so.
  • That looking at detailed case studies can help us to understand the barriers the system puts in the way of people getting the right care.
  • That there are big benefits when we move from a traditional ‘Assess – Treat / Do / Refer’ model to one that takes the time to understand people in their context.

Patient-shaped outcomes

This learning means we can support people in the city in ways that we would previously never have done.  In the video, James, who lives in Hove, explains how a conversation with his care coach meant that instead of spending Christmas day at home alone with a tin of baked beans, he was able to enjoy a sociable Christmas dinner with other people at Hove county cricket ground. This is the kind of real impact which our work in Proactive Care can have.

To find out more watch the video, and then visit the Proactive Care website at www.proactivecare.org

tagged in innovation, partnership working, Proactive care, service redesign, video

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