Hello, my name is Emma Bownas and I am proud to be an occupational therapist, working in Calderdale as the Deputy Director of Improvement for Primary Care.
You may be asking what Shepherds and Sherpas have got to do with population health management in Calderdale. Is it a new type of data warehouse that hasn’t yet been considered? Does it hold the secret to solve the data sharing intricacies that exist?
No, it is the type of approach that we have taken in Calderdale to support our primary care networks and localities to use population health management to benefit patients, clinical teams, and the wider system.
March 2020 saw Calderdale leap into the world of population health management just when the world was hit by a pandemic. A group of us in the NHS Clinical Commissioning Group could really see the benefit of using population health management to use data to identify groups of people who would benefit from a different health and care offer: proactive, personalised and tailored to meet their needs.
We recognised that the traditional offers and way services worked was not helping our people or our services and often resulting in poor health outcomes, overloaded services, and tired staff teams. We saw a great advantage in being data-led and invested in some external support from the National Association of Primary Care (NAPC) to join our team. Roll forward to October 2022, and we have had success within all our primary care networks (PCNs) including working together with local voluntary sector groups, community teams and social care as we strive to make population health management the way we do things around here.
Amongst the successes has been Ageing Well: a way of working that is being rolled out across all PCNs, utilising Ageing Well Practitioner Posts (from different professions including nursing, occupational therapy, and physiotherapy) alongside the additional roles in primary care networks, local authority, community, and colleagues from the voluntary sector. This has focussed on identifying people at rising risk of frailty; they may be visiting their GP more regularly, experiencing social isolation, starting to find things harder in everyday life. They are contacted and offered a conversation shaped around “what matters to them”. There may be medical issues to address, however, often the solutions are beyond improving a physiological marker.
The PCNs have taken a multi-disciplinary and multi- agency approach and now match up groups within cohorts with the most appropriate role within the team.
Evaluation is showing an improvement in health confidence within the group and a reduction in GP appointments. We are also looking to evaluate the impact on body mass index and HbA1c (a marker in your blood that identifies you as being at risk of diabetes) as an incidental marker and early results are showing a positive impact.
This approach to frailty dovetails with the work that takes place with people who are moderate to severely frail (who spend time as inpatients), and the specialists’ teams have been involved to ensure the development of a whole population approach.
Alongside ageing well, we have also seen work going on around people at rising risk of diabetes through the social prescribers and care co-ordinators in our personalised care teams. And across Calderdale a multi-agency meeting has been established to proactively work with people who are experiencing multiple disadvantages. This has positively impacted on people being able to maintain housing tenancies, providing a level of security for individuals to start and build a different future.
So why Shepherds and Sherpas? Well, the leadership approach to adopting population health management has been one of shepherding and sherpas. A farmer drives sheep from behind, catching the ones left behind, making sure they get to their destination but allowing some freedom to find the exact route, watching out for pitfalls, and navigating them to safety.
A sherpa leader is described as:
- one born to climb and connect
- a way marker (strategist)
- one who lets the environment produce the results – the environment and experience produces growth within the climber
- one who knows their role in the climb – it’s a guide, knows the way but can’t make the climb for them
- one who lets those they guide be heroes – celebrate the success of the climbers.
In Calderdale we have taken this shepherding and sherpa leadership approach. We have often referred to it as an evolutionary, organic process, going where the energy is and learning from failure as well as success. We have not waited for the ability to link data sets but have used what is to hand. We have been tenacious in the pursuit of progress and lit some fires.
There isn’t just one sherpa or shepherd, we have had a team, all with different attributes, expertise, and knowledge but the secret has been allowing the people climbing the mountain to complete their own climb.
It’s a part of my job I am really excited by as I have seen the difference this work has made for the people we service and the fire in the eyes of our health and care teams.
Have we reached the top of the mountain, are the sheep safely in the valleys? No; we have further to go but we will continue our journey.
Emma Bownas is an occupational therapist in Calderdale. This blog post was originally published by Calderdate Cares Partnership and has been republished here with Emma’s permission.
