This small town revolutionized healthcare with these simple practices

For a long time, Helen Kingston had noticed that a lot of her patients seemed dejected. A general practitioner in Frome, a charming English village two-and-a-half hours southwest of London, she had plenty of patients who were understandably worn down by multiple illnesses, who came in up to 80 times a year and needed more than a doctor could offer in a 10-minute appointment. But there were also many who felt helpless in ways that were harder to define.

Austerity, the government’s response to the 2008 financial crash, had led to dramatic cuts in jobs, children’s services, social care, school budgets, and local councils across the UK. That created real stress and health problems. But it had also, she thought, eroded people’s confidence to deal with the challenges life threw at them.

It wasn’t just the patients. Kingston’s fellow doctors were frustrated, too. They felt they were not able to offer the care patients needed, that they were only scratching the surface of their problems, both medical and non-medical.

Frome Medical Practice, where Kingston works, serves almost 30,000 people. But she had previously worked in a smaller practice, where she knew all her patients as people. She could tell that George was back in her office not because George had diabetes and depression, but because George had lost his wife and was feeling isolated and helpless, which was exacerbated by his diabetes and depression, and that to connect with people he needed extra support and help. She wanted to bring holistic and humanistic care to a larger setting.

So in 2013, Kingston applied for and received £110,000 ($142,000) of “innovation” funding from the Clinical Commissioning Group (CCG), an offshoot of England’s National Health Service that funds local GPs. She used it to hire someone to help manage patients who were being discharged from the hospital. But she also hired Jenny Hartnoll, a pathologically optimistic problem-solver, to map out community resources in Mendip county, population 115,000. Plenty existed: choirs, stroke support groups, exercise classes for people with health challenges, even Men’s Sheds, places—in the UK and around the world —where men gather to tinker build and bond. Hartnoll built a website cataloging all of them.

Then, Hartnoll designed a multi-pronged approach to get that information to people. First, she developed an army of very lightly trained “community connectors”—community members who could get out the word of what Frome had to offer. Later, she and Kingston designed a small team of professional “health connectors” who could help people manage multiple conditions and challenges. The approach addressed both ends of the distribution of medical care: those with seemingly non-medical needs and those with deeply complex conditions.

Patients and doctors got happier. But something else happened, in 2018, that catapulted Kingston and Hartnoll’s project from novel to national news: Emergency hospital admissions in Frome fell by 14% over three years. In Somerset county overall, where Frome is located, they rose 28.5%.

This was a big deal. In the UK, health care is paid for by the government which is expensive: From 1998 to 2013, emergency admissions rose by 47% in the UK, from 3.6 million to 5.3 million, costing the NHS £12.5 billion. Interventions to reduce emergency admissions have largely failed at a time when the NHS is often described as being at a “breaking point.”

Frome offered a dramatic counter-narrative. “We were absolutely astounded to find that as a result of trying to do what’s best for people the population emergency admissions had gone down,” said Julian Abel, a retired palliative care doctor who teamed up with Kingston to study the data. “There are no other interventions ever that have reduced emergency admissions across a population, in spite of this being public policy for at least two decades,” he said. They eventually published a paper in the British Journal of General Practice.

What’s happening in Frome is happening in different ways all over the world. In Wales and Canada, in Scotland, Australia, and the US, communities are building better ways to support individual needs. In part, that’s due to reality that the medical industrial complex can’t solve every problem, and countries can’t afford trying. But it’s also an acknowledgement that modern society is conspiring against us a bit, leaving it to communities to try and build resilience and unlock what makes humans thrive.

When the NHS released its 10-year plan in January, it included some of the core elements from Frome: the plan called for investing in “link workers”, or what Frome calls health connectors, and social prescribing, or having doctors prescribe community activities, similar in ways to what Hartnoll had been doing. “This represents a new relationship between people, professionals and the health and care system. It provides a positive shift in power and decision-making that enables people to feel informed, have a voice, be heard and be connected to each other and their communities,” the plan reads.

The question of course, is what exactly made it work in Frome, and can it be replicated?

The problem

On a cold, rainy Monday morning at the Cheese and Grain—a hip coffee shop in Frome—Jenny, 68, is talking about her 39 years as a surgical and recovery nurse. There was chaos, but also camaraderie. She had kids, and the juggling her many responsibilities was hard. But she was tough, she said.

She anticipated that retirement would be wonderful. And at first, it was. “The windows sparkled,” she said laughing and sipping her tea. “Then, there was nothing.”

Jenny didn’t have many friends. She had worked her whole life. Suddenly, she felt herself going downhill. She didn’t want to burden her kids (one lives in another country, the other is “very busy with her kids’ schools”) and while she has a husband at home, it was just the two of them, all day, every day. “You can talk to your family but they have to get on with their lives,” she said.

A person she met suggested she try the Talking Cafe, a group of people who meet and chat every Monday from 9am to noon. “Why not?” she figured. She walked in, sat down, and sobbed.

Jenny’s experience isn’t unique. Talking to friends and colleagues—or making new ones—has become increasingly hard, as technology both connects us and crowds out the time we might actually spend together. Jobs bleed into home life, and there aren’t as many collective places to gather: Libraries and parks are being auctioned off by councils to developers to raise money, and church membership is in free fall. In pursuit of Instagram-ready perfection, many of us sacrifice the familiar comfort of regular friends, whose imperfections IRL remind us that ours are okay too. Online, everyone can be perfect.

“Most of us have got friends and we neglect them a little bit,” Kingston says. We think they’ll be there when we need them, but it’s harder to call asking for help when you haven’t called in a year.

As a result, people may be leaning on their doctors for comfort and guidance they might have gotten from family, or friends. The average member of the public now sees a GP six times a year, double the number of visits from a decade ago (the population is up only 10% in that time). “Primary care in England is where they come when they aren’t sure what they should do,” Kingston said. People come in with medical issues—but often, it’s more than that. “When you dig down it’s a medical condition, and the impact of the medical condition on their lives.”

Research in 2016 showed 20% of patients consulted their GP for what were primarily social problems; more recently, an NHS England report (pdf, p.10) said that had shifted to half. “People struggling with life alongside their health are less able to cope with ill health, or they find themselves ‘medicalizing’ this struggle in order to get help,” said a recent report by London South Bank University’s Health System Innovation Lab (pdf, p.8).

In Frome, Kingston and Hartnoll have worked to rebuild those lost support networks, to connect the community and the health care system better. Hartnoll, whose official title is “services lead” for Frome Medical Practice, came up with the idea of community connectors—essentially, giving people the green light to help anyone who seemed like they needed help. Starting in 2013, Hartnoll recruited connectors wherever people gathered: churches, cafes, schools, police stations. To keep it simple, she offered a training between 20 minutes and two hours. More than 1,000 showed up.

Hartnoll gave them a simple mandate: know what is available and point people to it. Say you’re in line at the grocery store, and discover the person in front of you’s mother had just had a stroke. You might say you’d heard of a stroke support group and then pass them a card with Health Connections Mendip—which has the directory of services, and contacts for one-to-one support.

She did more than aggregate the groups: her team acts as an incubator, a transition team, and an advocacy group. If people want to start some kind of support group, they go to Hartnoll. If their group is struggling, she helps. If someone dies, leaving a group leaderless, she takes over until more help materializes. “I love making things happen,” she said. In total, the Health Connections Mendip site now references 400 groups, including ones Frome Medical Practice runs such as ones focused on pain management, On Track goal setting and the Talking Cafes, and ones individuals run.

Jenny, the retired surgery nurse, has been coming to the Talking Cafe every week now for almost six years. She looks out for people like her—people who need help, or just a chat, but maybe don’t know how to ask.

She and Linda, 70, have struck up a friendship. They compare notes on a laundry list of health problems (says Linda: “When people ask ‘How are you?’ you say you’re fine, but you’re not fine”). Jenny holds court at the end of a long table, helping a newcomer (57, also in tears), who had just lost her husband, then turns to Jeffrey, 91, who she calls “love.” He smiles, a bit sadly. But he has been seen.

The medical model

Mapping the community and building out the support groups was the first part. Next came help for the frequent fliers, or those patients who visit the NHS up to 80 times a year. That required rethinking the medical model.

In 2015, Kingston secured more funding (£309,000), including a chunk from the independent Frome town council, and the CCG. They hired almost half a dozen health connectors and two district leads, professionals trained to help patients who might have three of four conditions and need help managing them.

As Hartnoll built out the community connectors and health connectors, Kingston tried to weave the the primary care model together to make it easier for different parts of the medical system to work together: district nurses, social care, GPs, mental health workers and hospital staff, health connectors.

She put in place multi-disciplinary team meetings which take place three times a week during which GPs, community connectors, health connectors, social workers, district nurses, and the hospital discharge liaison map out how to support particular patients (rather than endlessly referring, which is both impersonal and inefficient). As a group of humans, rather than departments, they decide who is best placed to assess and help an individual. “In some cases this will not be any of the traditional health and social care teams but community organizations now linked into primary care,” Kingston said.

It becomes a cycle: community care bolsters the medical practice, while medical care bolsters the community work. Success happens when individuals find what they need through the community itself or their own networks, but also, if that’s not enough, they turn to their GP who can draw on community resources as well as traditional health ones.

Take Stan and Julie (not their real names). Kingston visited them recently, as she does house calls for the vulnerable and immobile. Julie had a respiratory condition, Stan is dying and has palliative care. Julie is falling more and struggling to take care of herself, and him. They are stressed, and can’t get to the store for food. But they want to remain in their home, in charge of their lives, as much as possible.

Kingston brings up the couple at the meeting. A health connector agrees to visit and talk to the couple to understand what matters most to them, and what services and support they might need. They map out some help: meals on wheels, some additional care in the morning to make sure he can be bathed and dressed, someone to bring them fresh vegetables to cook. With this, Stan and Julie can stay at home together, in charge of their own lives.

Small tweaks to the system have had massive effects. Hartnoll put in place an umbrella IT system to allow multiple doctors access to the health connectors’ notes to see how they were supporting the patients. Over time, as trust grew, the doctors allowed the health connectors access certain doctor’s notes which could help them support the patient.

The team also created a keyboard function for the software—F12—to allow doctors to quickly and easily access the Health Connections Mendip directory. With that, they can refer patients to relevant services like bereavement support or mobility options instead of scrolling through an inbox of 5,000 emails to find the flyer about mobility support, a practice Kingston says is not possible in the space of a 10-minute appointment.

As emergency admissions fell, so did cost. From 2013-2014, the cost of unplanned admissions in Frome was £5.8 million; in 2016-2017 it was £4.6 million, a 20.8% reduction. Downing Street took notice and awarded Kingston a “Points of Light” award for public service and Camilla, the Duchess of Cornwall, paid a visit.

A new model for being human?

“If you look at the medical model, everything is a diagnosis and a treatment. It’s all very linear,” Kingston says. “Lives are not like that.” The average Brit interacts with the NHS five to 10 hours a year but spends 8,750-8,755 hours a year on self-management. Make the self-management part easier, and that makes the five to 10 hours more effective.

The twist? Kingston built this effort using primary care as the backbone, making sure the system takes care of the most vulnerable: those leaving the hospital and those with complex needs, but also catering to those who don’t need medical help as much as more social connection. “We are social beings,” she said. “If you move the curve from lower interaction to higher it has a huge knock on effect.”

By integrating the medical, emotional and practical elements of care, around people—in all their glorious individual messiness—Kingston and Hartnoll unleashed the power of relationships to elevate systems, be they human or medical.

Kingston insists that nothing Frome has is unique: The unique bit is weaving it together, at the individual, GP, and community level.

People are not clusters of symptoms but individuals with histories, and wants. She wants the medical system to reflect that, and also the community. “The logic of human beings is the same, isn’t it?” she says. “If you trust people right you usually get the best out of them.”

Communities around the UK and the world are borrowing from the Frome playbook, some having visited Frome for a bit of inspiration, including from Sheffield, Totnes, Stroud, Wales, Bath, Bristol, and Australia. David Boyle, who has done independent reviews of public services for the UK’s Treasury and Cabinet Offices, visited Frome as part of his research. “The sheer scale of it is amazing,” he said, noting the 1,000-plus community connectors. “Having something that works locally and then building it across a wide area, it’s a huge achievement. It’s brilliant.”

Kingston and Hartnoll have spoken at about 30 conferences, and been visited by 50 organizations or interested individuals (some paid; some not). They want more secure funding to move the model ahead: budgets are tight. Hartnoll cries when she talks about how hard Kingston is working; and how much she asks of her own team.

When people come to see the program, as many do, they often ask Kingston what the governance framework of the system is. Where are the rules? Kingston smiles ever so slightly. The point is not making and following rules; it would have to be a mighty long rule book to account for every possible iteration of every human life. “There were lots and lots of rules and guidance about what the evidence says you should do,” she says, “but what happens is that is evidence for the disease, and not for the person.”

Some try to chalk up the success to the community Hartnoll has tapped, or unleashed. Others point to the work Kingston has done to make medical care more cohesive and human. Hartnoll has a different take: “It’s everything and everyone doing their bit that makes the difference.”

It’s not more services or offerings as much as a it is everyone feeling they are part of the offering: a meal, a ride, a bit of compassion, and help piecing life together when everything falls apart. It’s giving people the services they need but also building the resilience they have.