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Open door - healthcare and more for those most in need

The Open Door project has made a real connection with patients who would otherwise not access primary care services. Lance Gardner explains

The Open Door project has made a real connection with patients who would otherwise not access primary care services. Lance Gardner explains

By any standards set by the Department of Health, North East Lincolnshire Primary Care Trust – now Care Trust Plus – could be considered successful. It has consistently achieved three-star status and been acclaimed as a top-25 PCT.

But when CEO Jane Lewington saw evidence from health needs assessment work undertaken by two specialist health visitors showing that the PCT still had 1,000 people who were not accessing traditional primary care services, she wanted to address it. In Jane's view, if the PCT wasn't meeting the needs of its 1,000 most vulnerable individuals, it was a failing PCT.

The open-door concept

Open Door is an activity and social centre funded entirely by the care trust. It has a cafe, Citizens Advice Bureau, kitchens for cookery classes, alternative therapies, showers and flexible activity space that is open to all.

Each of these facilities provides people with a reason to be there, a place of safety and the means to socialise. Their time can be productively occupied by appropriate and genuine activities, facilitated eventually by service users as volunteers – thereby providing a development path to respect and self-esteem.

From the outset we were keen that Open Door be a demand-led service to ensure it met the needs of its users. So when we started to consider the clinical services we would provide, we were aware that we couldn't employ our own GP.

So we set up a retainer contract with a local practice, Ashwood Surgery, which provides us with sessional input by one of its GPs.

This GP is on site at the Open Door 12 hours a week and will also see Open Door clients at the surgery.

Open Door is an active member of the PBC locality (there are four in North East Lincolnshire) and GPs have welcomed our innovative ideas and somewhat wacky ways of working.

I think one of the key reasons for GPs' acceptance of us is our social enterprise status – we are a for-profit company but all profits are ploughed into care. Therefore we are not seeking high financial return or personal profit.

The only real bone of contention we have had within the PBC locality has been around our referral activity and prescribing. The obvious option was to top-slice the other practices to fund our activity but as 80% of our patients were unregistered before they came to us they were unfunded and therefore our locality group was subsiding this new population.

Fortunately the referral and acute activity has been so low there has been minimal impact on the PBC group's budgets.

Our reluctance to build a large registered list, which might have threatened the patient base of local GPs, has facilitated the good relations we have. Indeed, our relationships with local GPs and the PBC group has been much better than we could ever have anticipated.

First steps

In 2006 the Neighbourhood Renewal Fund (NRF) handed over £50,000 to project designer Martin Bontoft to research and produce the model for a new service. This service would deal with the complex social issues that result in ill health and low engagement with traditional services.

The aim was to improve access to healthcare for Grimsby's vulnerable groups without disenfranchising the mainstream. Particularly vulnerable are drug users and their dependents, sex workers, homeless people, offenders and foreign nationals seeking either asylum or work – estimated to number some 6,000 people in Grimsby.

We heard stories of professional arrogance, poor communications, disjointed services, prejudice and rejection. We heard the NHS being vilified, but also of the strong relationships forged between individuals and their professionals and when asked why, it was usually because ‘they listen'.

The picture that emerged was of people with complex, individual needs and simple generic needs, interestingly much more motivated by the latter – people who didn't trust the NHS per se, but who deeply respected carers who they felt respected them – and others with skills and aptitudes but no appropriate outlet to express them.

A prototype service design emerged, which was further developed and refined with potential users and the NHS team.

As well as our sessional GP, we now have our own practice nurse (20 hours a week) and a full-time lead clinical nurse who does the case management. A counsellor works here 10 hours a week and a consultant psychiatrist does a fortnightly clinic.

Other staff include a senior case manager, a CAB officer, two health trainers, three support workers, a practice administrator and a general manager.

We also have ad-hoc sessions by probation officers, a learning disability team, a community mental health team and housing officers.

We are currently open 10am-4.30pm every day and one evening a month 6pm to midnight to provide a specialist service for sex workers. We aim to open until 10pm two evenings a week from November.

Funding and structure

Open Door is run as a self-sustaining social enterprise but with a PMS contract.

Open Door Care is our core business and delivers the social side of the business. It is a company limited by guarantee with an asset lock. This means we are never able to sell our goodwill or any other asset belonging to Open Door.

In the future we hope to develop public membership and share ownership without dividend for Open Door. But the asset lock means that even if all the shareholders voted to sell up and take a share they would not be able to.

Open Door Health is a subsidiary of Open Door Care and was created as a legal vehicle for the PMS contract. It is a company limited by shares and the three directors are myself and the two specialist health visitors whose idea this originally was.

In terms of set-up costs, the NRF gave us a further £70,000 in 2007/8 for set-up costs and we are currently looking to secure local authority funding through the ‘Supporting People' initiative.

As a Department of Health Social Enterprise Pathfinder, the DH funded us £90,000 over two years for legal costs, project management costs, company set-up costs and so on.

Finding our patients

We started with 23 patients who were allocated to us by the PCT. These 23 had a history of challenging or unacceptable behaviour within traditional general practice. Although it did include the anticipated group of ‘angry young men',

it also included a 63-year-old gentleman with COPD and an 82-year-old quadriplegic lady. We also have the DES contract for treating violent patients for North East Lincolnshire and our neighbouring North Lincolnshire PCT.

Because our team has the expertise to deal with challenging behaviour we have no overt security measures. There are no glass partitions, no CCTV, no locks on doors – there isn't even a reception desk. As part of our contract we accept all patients allocated to us by the PCT and have pledged never to remove anyone from our list because of challenging behaviour.

That said, this pledge has yet to be tested in the heat of extremely poor behaviour.

There was relief by many practices that some of their more challenging patients would be able to access a facility specially prepared to manage their chaotic and often disruptive behaviour.

We are not seeking to build a huge registered population, but simply to meet unmet need where that exists. If an individual attends Open Door for care but is already registered with another practice we discourage them from registering with us but work with them to build an improved relationship with their existing GP surgery.

During our first year of operating we have registered 360 people and more than 2,000 people have accessed services of some description at Open Door.

The local A&E automatically refers anyone who attends there who isn't registered with a GP to Open Door, and the police work with us to support prolific and priority offenders.

Health needs

The morbidity of the registered population demonstrates the unique nature of the challenges faced by Open Door. The age profile means that most of our clients are under 50 with no history of chronic disease.

An inability to manage money well or afford a balanced diet leads to the majority of the patients being underweight. Morbid obesity is rare.

We only have two patients with diabetes and four with epilepsy. However, our incidence of mental illness is such that our consultant psychiatrist recently wrote to the PCT expressing his concern that Open Door had identified nine individuals suffering from severe mental illness who appear to have never received any mental health care anywhere in England.

Open Door has been a success when you look at the targets we were set by the care trust (see box above). However, from a PMS performance perspective we are a very low achiever – we only earned 300 QOF points last year.

Reflections

As with all innovations, our first year has been a bit of a rollercoaster ride. I think the key issues have been around having sufficient capacity to meet the needs of the service users but not having so many staff that they are falling over themselves for something to do.

One of the most difficult elements for us to get right was the balance in the effort we put in to engaging with stakeholders.

Because we were dealing with so many diverse client groups the number of stakeholders affected by our activities was just enormous. Inevitably there has been tension and a bit of friction at times but we have worked hard on maintaining good and constructive relationships wherever we can.

We have been able to have the same GP doing all our sessions at Open Door, which means we get continuity of care and can create therapeutic relationships with clients who are reluctant to trust anyone. Ashwood's support has been invaluable and we would have really struggled without it.

However, the collaboration has had a very detrimental effect on the practice's prescribing activity. It went from being ranked second lowest prescriber of benzodiazepines to the highest in two weeks.

This is because we naively started to manage patients who were using controlled drugs and therefore denied access to specialist drug services. Word soon got round that we were prescribing benzos and we were inundated with clients looking for a legitimate supply of something they had been happy street-buying for years.

We soon had to establish firm ground rules – they must have an active prescription from another GP, or they must have been released from hospital or prison with a prescribed history of benzo use. A year ago we had 20 clients on benzos; today we have four.

Open Door is now recognised as a legitimate advocate for vulnerable people and marginalised groups and so we are frequently asked to comment on the suitability of proposed services for the people we help.

The future

We have toyed with the idea of giving up our PMS contract and not providing any medicine at all, but we are committed to delivering a full and comprehensive service and healthcare is an integral part of this. But we still aren't convinced PMS is the right contractual vehicle for us. We may end up with some kind of PMS-APMS hybrid.

In October we will move our clinical services into a separate building 50 yards away from our social site. This is because we have recognised that medical services dominate the behaviour of both staff and service users alike, yet we have a relatively physically healthy population who assume an illness model the moment they meet a doctor or nurse.

This move will also enable us to provide PMS services to the wider population of East Marsh, one of the most underserved but socially and economically deprived wards in England, while protecting our commitment to delivering a wellness model.

We are also hoping to develop a ‘Supporting People' team because housing issues predominate among our service user population. We are adapting our governance model to create a sense of ownership by our staff and users. We will have a membership scheme that will entitle staff and users to have their say and vote on future developments.

Lance Gardner is managing director of Open Door, based in Grimsby, Lincolnshire

Lance Gardner: our activities and facilities mean clients have a reason to come here Lance Gardner 60-second summary Open door's targets

Open Door proves its outcomes to the care trust from a variety of measures.
We have measurable targets for numbers of:
• unregistered people who visit us
• TB contact tracings
• service users who open a bank account with our supporting bank Abbey Santander
• service users assisted in acquiring accommodation and supported to retain their tenancies
• clients who get work because of Open Door
• clients entering full-time education
• clients achieving an educational qualification (English
as a second language, basic skills)
• people attending anger management classes (in-house by our senior case manager).


We have targets for reduction in criminal activity by our service users and in the electoral ward in which we are based.
We also have a target to cut A&E attendance.

Open door has identified 9 people with severe mental illness who have never been treated before

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