Developing and implementing non-traditional health and social care roles to improve primary health care

Developing and implementing non-traditional health and social care roles to improve primary health care for older people in England

Recognizing the need to manage the care of older people in a proactive and age-sensitive manner, colleagues at the Sandgate Road Surgery primary care medical centre in Folkestone, United Kingdom, have been working to manage emerging risks among older people and help maintain their independence at home.

Given the initial successes their Pro-Active Care (PAC) service, a second service at the Sandgate Road Surgery, called the Over 75 service, embarked on a larger pan-European project called SUSTAIN to further improve the delivery of integrated care to their older patients.

Health needs increase and require unique attention with age. If not addressed at the primary care level, on an as-needed basis and close to people’s homes, older people are at risk of deteriorating more quickly and losing the chance to continue living independently at home.

The danger, however, is that primary care services can become overly concentrated on the 2% of older people who are high consumers of services and neglect those with less acute needs but who nonetheless require proactive care to avoid deterioration.

The PAC service

In January 2010, General Physician Dr Tuan Nguyen arrived at the Sandgate Road Surgery as a partner. Faced with an enormous need for proactive interventions for older people to help them avoid the risks of living with multiple long-term conditions, Dr Nguyen introduced the PAC service. He had created the PAC service while working in Liverpool, United Kingdom, with a similar population.

Dr Nguyen describes the key aim of the PAC service: “We wanted to develop a flexible system, with a community team that included health, social services, community services and third sector groups to help deliver improved patient sense of health and well-being and independence.”

In 2015, the London School of Economics and Political Science (United Kingdom) evaluated the impact of the PAC service in Liverpool and Folkestone. The results showed that the average number of monthly attendances and admissions decreased by 49% for patients who had completed the original PAC programme. Quantitative analysis also demonstrated that hospital costs for these patients decreased by about 70%.

Over 75 service engages non-traditional health- and social-care roles

However, with the identification of greater numbers of new patients to manage, the PAC service was increasingly strained. Furthermore, the mounting financial pressures on health and social services and the significant decline in numbers of general practitioners and nurses also posed a threat.

In response, the Over 75 service recognized that many of the interventions that were effectively engaging less acute patients did not necessarily need to be provided by professional health- and social-care staff. It therefore reached out to involve a range of locally available non-traditional health- and social-care roles. Today, these non-traditional roles support the needs of older people who require less intensive, preventative support in the following ways.

  • The health trainer supports people to live independently by helping them make adjustments to their lifestyles, become more active or make dietary changes. This helps people to maintain their state of health and improve their quality of life.
  • The care navigator is part of a separate care and support agency called Family Mosaic. They support older people to live independently by organizing other services such as meal delivery and equipment services, and by directing them to opportunities in the local area, such as clubs and groups, that enable them to stay safe and independent at home.
  • The personal independence coordinator (PIC) is part of a personal independence programme offered by AGE UK, a voluntary organization supporting older adults. The PIC works with people on issues associated with long-term conditions such as loss of confidence and social isolation. People are linked to local groups and support services and, where necessary, a volunteer is matched to an older person to provide ongoing support. By reducing people’s anxiety, their dependence on the Sandgate Road Surgery and other formal health-care services (such as accident and emergency centres and out-of-hours calls) is also reduced.
  • Last but not least, the Sandgate Road Surgery employs the paramedic practitioner to undertake urgent visits that would traditionally be carried out by a general practitioner or nurse practitioner. As a result, more time is made available for doctors and nurses to carry out other activities that are part of the PAC service.
Factors of success

Steering group

When asked about key factors of success, Sister Julia Baldwin, Lead Nurse and Practice Matron at the Sandgate Road Surgery, explains that an important factor that helped steer the planning and implementation of such a multidisciplinary response was the support of the EU-funded SUSTAIN project. SUSTAIN guided the group to set up a steering group representing all the services involved as well as the local clinical commissioner.

Sister Baldwin explains, “Working with the project, we needed to find a constructive way to bring together this range of skill sets and services working with patients to share information across disciplines. This fosters better relationships between agencies.”

Because the clinical commissioner was included in the steering group, the commissioner was able to disseminate information about the new roles and ensure the alignment of these services with the primary care services offered at the Sandgate Road Surgery.

As Dr Nguyen notes, “Through its inherent flexibility and joined-up, multiagency working, the SUSTAIN approach has been adopted as an integral part of local care delivery for the whole of the area.”

Multidisciplinary teams and relationship-based services

An understanding of the function of these roles and how they operate was shared not only through the steering group, but also in multidisciplinary team meetings designed to implement the integrated service.

“Information-sharing at multidisciplinary meetings provides unique insights into other agencies and also has an educative element,” Sister Baldwin continues. “The multidisciplinary approach has always been a key principle of the service and instrumental to its continued success. It also reduces wastage of resources by limiting duplication of care.”

Over time, trusted relationships have developed. The professionally trained and registered staff (nurses and social workers) now see the care navigator, health trainer and PIC as equal and valuable members of the team.


Funding of these roles has been crucial, and thus threats to long-term funding for any role could jeopardize these collaborative efforts.

A common vision

The steering group shares a clearly defined organizational vision and a commitment to deliver care that is preventative, holistic and person-centred. The recognition that the new roles help enable this has also contributed to their adoption within the service.

Measured improvements

Partnerships with universities have been an effective way for both the PAC service and the Over 75 service to continue their initiatives through the evaluation and measurement of improvements. Researchers from Kent University (United Kingdom) and partners of the SUSTAIN project and are currently carrying out a multimethod evaluation of the service, focusing on the themes of person centredness, prevention, safety and efficiency.


SUSTAIN’s overall aims are:

  • to improve established integrated care initiatives for older people living at home with multiple health and social care needs, ensuring they are patient-centred, prevention-oriented, efficient, resilient to crises, safe and sustainable; and
  • to ensure that improvements to the integrated care initiatives are applicable and adaptable to other health systems and regions in Europe.

SUSTAIN will be presenting the results of the evaluation of the Over 75 service in Folkestone, in addition to evaluations from 13 other integrated sites across 7 countries in Europe: Austria, Estonia, Germany, Norway, Spain, the Netherlands and the United Kingdom.

It will also present a roadmap to guide policy-makers and decision-makers in designing and implementing similar services. Member States are invited to participate in a review of the roadmap for feasibility in their countries. The review will start on 15 October 2018. Those interested should email:

SUSTAIN is funded by Horizon 2020, the European Commission’s funding programme to support research activities.

See original post here in the WHO, Health topics 

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