What good integration looks like in practice: a case study from our Persistent Physical Symptoms prototype

The government’s 10-year plan for healthcare in England, published yesterday, emphasises local, personalised, holistic healthcare, delivered by strong multi-disciplinary teams with non-clinical support at their core. For that to become a reality, good integration will be key. So we chatted to Tracy Huitson, Practice Manager at West Road Medical Centre in Newcastle upon Tyne, and our own Steffen Laukard about how they’ve worked together to bring this vision to life.

Persistent physical symptoms (PPS) – uncomfortable, distressing and sometimes debilitating sensations in the body that occur over a prolonged period, in conditions like fibromyalgia, chronic pain and irritable bowel syndrome (IBS) – account for about 20-40% of GP consultations, and around 60% for some hospital doctors[i]. Our PPS prototype, led by Steffen, was developed in response to that, to test whether holistic, long-term relational support by specialist link workers could form an effective part of the solution.

A year in, early data from the programme is showing real promise, and West Road, which is one of the primary care practices involved, told us they feel much of this preliminary success is down to the way the team is integrated into the system.

Tracy leads a team that looks after 12,250 patients in Fenham. She said: “I would say the PPS programme is extremely integrated and I think that has been because we’ve had Steffen devoting that time at an early stage to come in and get to know the doctors, get to know the staff, and come to our multi-disciplinary team meetings (MDTs).

“This means that although we understand it is separate to our practice, it feels like just another service within the team. I know from overseeing a lot of services that that’s been key to this one really working. All the doctors are aware of it and are using it, so it is really integrated.”

Building good foundations

Initially, Steffen was based in the surgery for two afternoons a week and attended as many MDT meetings as possible, spending time with both the admin and medical teams to understand the practice’s procedures and culture.

He explained: “MDTs have been a treasure trove for me. As link workers, we are not clinicians and don’t always know all the medical jargon that patients may refer to, so having the opportunity to say, ‘look, I’m a bit confused; can you explain this to me’, or ‘I’m stuck; what do you think we can do here’, or perhaps just convey what we feel a patient has come to us with, is so valuable.

“I’ve had experience across a few GP practices and having an MDT where you feel you can talk and be listened to is very much appreciated, as well as being useful for our clients.”

Tracy feels that referrals to the programme were highly dependent upon Steffen having made himself such a collaborative member of the West Road team. She said: “Having you in the practice means the PPS project is in everyone’s minds and we understand what it is.”

Breaking new ground

Having spoken with her colleagues about their impressions of the pilot up to now, she added: “Everyone has given outstanding feedback. Words that were used included ‘excellent’ and ‘groundbreaking' and I would agree with that. I think it is groundbreaking in particular in that it’s tackling a whole group of patients who are suffering from an unmet need.

“I think we’re all aware of that unmet need, but no one has taken the bull by the horns so to speak to try and deal with that. The thing I find exciting about it is that it’s a long-term intervention, and that’s quite refreshing because it gives us a chance to really see what difference it makes.”

Balance is key

Tracy continued: “We are now in the phase where we’re collecting that quantitative evidence, but we already have many anecdotal stories we can tell that show the positive impact in people’s day to day lives.

“That’s really refreshing – to have a project that understands you’re not necessarily going to get robust statistics at this early stage, but case study feedback like this that goes back to GPs – and over a long period of time – is really powerful, and these improvements are hard to measure but will make a huge difference to people.

“From experience, it’s hard to get funding for services to work on that basis, but it’s really important not to ignore things because you can’t evidence a statistical improvement immediately.”

In it for the long haul

“It’s not a programme for only six weeks that thinks ‘we’re going to change patients’ lives’, Tracy added. “We’re talking about patients who’ve been experiencing their feelings or their pain for many, many years. It’s not just going to change in six weeks.

“So it’s good that it’s also allowed to be vague in terms of patient experiences and what the objectives are with individual clients, because it works on the basis of what’s important to them. And I think that’s really important. If you pigeon-hole you just restrict the sorts of patients that can be referred.”

The agility to which Tracy refers is built into all our prototypes, which are based on a test-and-learn approach, sharing the learning among stakeholders throughout the process to feed positive and sustainable systemic change for the benefit of patients.

Added value

Steffen said: “It’s about the idea of finding the pathways for improvement within the system that will ultimately improve quality of life for our population; that’s what we’re all about at Ways to Wellness. Through the test-and-learn approach you can get an understanding of what has the biggest impact upon the patient as well as what that does for the system involved in the care of that patient.”

Tracy added: “Ways to Wellness provided us with some training the other day and we felt really lucky to have that opportunity. In addition to its specialist link workers, Ways to Wellness has all this research and all this evidence to try and help us educate our teams as well, so that feels new.

“I hope the PPS project stays for the long term and has a chance to shine through its evidence so that everyone gets to understand how groundbreaking it is. I think that will be easier to evidence over time with these groups of patients, and that it can become a learning point for other parts of the country. We would very much like to keep it embedded in our team.”

Next steps

A formal interim evaluation into the PPS prototype will be completed shortly, and we’ll be publishing more thoughts on the government’s 10-year plan too. In the meantime, find out more about the project at waystowellness.org.uk/persistent-physical-symptoms – and get in touch if you feel we could partner with your organisation to test a non-medical intervention you feel would improve patient’s lives.

[i] https://pmc.ncbi.nlm.nih.gov/articles/PMC11151618/ and https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(24)01242-X/fulltext