Rapid test sites

 

There are 14 rapid test sites that have been leading the way in developing the primary care home model. 

 

1. The Breckland Alliance

2. Larwood and Bawtry

3. South Bristol Primary Care Collaborative

4. Eden

5. Aspire Integrated Rugeley

6. South Durham Health Community Interest Company (CIC)

7. The Healthy East Grinstead Partnership

8. St. Austell Healthcare

9. Thanet Health Community Interest Company (CIC)

10. Wolvehampton Total Health

11. Winsford Group

12. Beacon Medical Group

13. Luton Primary Care Cluster

14. Richmond

 

 

 

1. The Breckland Alliance

 

Overview 

The Breckland Alliance has seen three GP practices in two small towns within a deprived, relatively isolated community come together to provide mutual support in an area which has struggled to recruit and retain GPs as well as cope with demand. The vision was to collaborate to develop a sustainable primary care service for their population ensuring the most challenged practice remained open and offer patients improved services bringing services closer to patients’ homes where possible.

 

How things are changing 

 

Shortly after creating a primary care home and a new structure, one of the alliance’s practices hit a crisis. The response was to put a funding proposal to NHS England to stabilise the Watton Medical Practice. The practice had been forced previously to redefine its geographical boundaries and was in danger of closing. The PCH enabled the practices to support each other and plan for the delivery of primary care at scale.

 

Patients still have a surgery in Watton which would have otherwise closed. Staff are now collaborating and working across all three sites. Partners from the two Thetford practices have been covering clinical and management sessions at the Watton practice to help stabilise it. A clinical board has been established to oversee its working, involving partners from all three practices. A clinical nurse manager works across the three sites and is working towards building one cohesive team across the PCH. To measure the impact, the primary care home is tracking patient satisfaction at Watton, which was previously very low, and the use of locums.

 

In the future, the alliance will enable the surgeries to invest in staff, improve back office services such as finance and IT and develop new services for patients. These are likely to include bringing hospital-based clinics into the community, so reducing travelling time for members of the public, as well as developing health and wellbeing services to stop people becoming unwell in the first place. A focus is likely to be on the large number of elderly care homes in the area. It is hoped that more proactive care and routine medication reviews for residents will be delivered in the homes to improve health and wellbeing and optimise prescribing.

 

Lessons learnt have included the need to break down a culture of each practice working in isolation and make them more open to collaboration.

 

Partners

 

Three GP practices, South Norfolk Clinical Commissioning Group, Norfolk and Suffolk NHS Foundation Trust, Norfolk and Norwich University Hospital NHS Foundation Trust, West Suffolk Hospitals NHS Foundation Trust, West Suffolk Clinical Commissioning Group, Norfolk Community Health and Care Trust, other local community providers and social services.

 

 

2. Larwood and Bawtry

 

OVERVIEW

 

Larwood and Bawtry Primary Care Home covers several villages in Nottinghamshire and South Yorkshire, some of which have high levels of deprivation and disease. Two practices wanted to build a new primary care team to care for their local populations and work in partnership with other organisations to ensure services improved and remained sustainable. The primary care home is improving the way the practices work together and bringing in new partners to improve services to patients. It has three aims: to improve staff support and wellbeing so they can cope and stay well doing an increasingly difficult job, improve patient outcomes particularly by identifying issues before they become acute and find increasingly efficient ways of working.

 

HOW THINGS ARE CHANGING

 

The two GP surgeries have created integrated teams co-locating community and voluntary services in the practices. Community matrons and community nurses work with practice nurses in integrated neighbourhood teams. The practices provide administrative support to the community service staff, resulting in better exchange of information between GPs, practice nurses and the community teams.

 

Community advisors funded by the voluntary sector now work from the surgeries, running citizens advice clinics signposting patients to voluntary and non-medical services in the area. They provide a vital link to services that can address some of the underlying causes of anxiety and depression including debt and unemployment. Close working with the district council has led to improved support in care homes and for people with housing needs. Social care clinics are held on site enabling patients to receive quicker needs assessments.

 

There’s been a 5 per cent reduction in prescribing costs following the appointment of an in-house practice pharmacist who carried out medicine reviews for care home residents. Analysis over a seven-month period found a significant reduction in prescribing costs and projected

 

£229,000 annual savings, as well as reducing the risk of side-effects for patients. Emergency admissions dropped by 8 per cent over the same period with the clinical commissioning group estimating savings of £277,000.

 

Staff are working together better and find work more fulfilling (87 per cent of staff surveyed felt the PCH way of working had improved job satisfaction). Patient care has improved with better information among staff and care plans integrated across services.

 

Lessons learnt have included the need to engage staff and have a ‘do and build’ attitude.

 

PARTNERS

 

Two GP practices, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Nottinghamshire Healthcare NHS Foundation Trust (community and mental health services provider), Nottinghamshire County Council (social services), Bassetlaw District Council, Bassetlaw Community and Voluntary Service and Bassetlaw Clinical Commissioning Group (CCG).

 

 

 

3. South Bristol Primary Care Collaborative

 

 OVERVIEW

 

Six practices in a deprived part of Bristol have come together with the city’s community health services provider, Bristol Community Health, to develop new services to improve the health of the population. The area is one of the most deprived in the country, with high levels of health inequalities and disease.

 

The practices were concerned that on their own they would no longer be sustainable and wanted to collaborate to deliver primary care differently. Becoming a primary care home gave them an opportunity to move away from struggling on their own and do things differently - together and with new partners. The vision is to create a multi-specialist team providing primary care services for their population, where the patient gets the right treatment at the right time. The primary care home is run by an executive committee with a memorandum of understanding between the six practices and Bristol Community Health. It has close links with the Bristol Clinical Commissioning Group and the public health department of Bristol City Council.

 

HOW THINGS ARE CHANGING

 

The collaborative has developed teams of nurses and paramedics who provide a rapid response to urgent calls for home visits from the frail elderly. Previously, GPs could only make home visits in the afternoon when it was often too late to intervene usefully with new medication, care arrangements or assessment at hospital. Now the teams attend quickly, early in the day, and make new arrangements for prescriptions, nursing, social support or hospital assessment. This means people who are frail, housebound and acutely unwell get appropriate care sooner. Doctors brief the practitioners before the visit and there is a debrief with a doctor afterwards. The practitioners (two nurses and two paramedics), employed by Bristol Community Health, are funded by the Better Care Fund and the clinical commissioning group but their clinical workload is allocated by the practices, crossing cultural and organisational boundaries.

 

Integrated community dressing clinics have also been developed. Instead of patients going to see a GP or nurse for a wound dressing, or requiring a home visit from a district nurse, an offsite wound dressing clinic has been set up, once a week, in a local community centre, in a semi-social setting. Bristol Ageing Better provides transport. This means people have a social as well as clinical experience, which reduces their isolation and improves their mental wellbeing. There is a large and active patient participation group with a patient champion who are engaged and helping to define the development of new services.

 

Lessons learnt have included the time it takes to build trust and relationships and the need to challenge a culture of ‘silos’ where people naturally focus on their own businesses. Challenges continue to be limited funding.

 

PARTNERS

 

Bristol Clinical Commissioning Group (CCG), Bristol City Council (BCC) and the Better Care Bristol Vision Governance Structure, Brisdoc (the GP out of hours service,) University Hospitals Bristol NHS Foundation Trust.

 

 

 

4. Eden

 

OVERVIEW

 

The Eden Primary Care Home was created by local GPs from four practices struggling to recruit staff and sustain services who wanted to change the way they work to improve services for their isolated and older population in Cumbria. Developing a primary care home was seen as a way of creating sustainable, integrated services which better met the needs of the population and made their organisations more viable.

 

Their vision is to provide better care for patients, through an integrated service which avoids many different visits from different service providers and brings care closer to home avoiding the need for patients to travel miles to hospitals in Whitehaven, Carlisle and Penrith.

 

HOW THINGS ARE CHANGING

 

The primary care home has led to more integrated working between GP practices, and between district and practice nurses. It has enabled a number of specific projects including the introduction of new non-clinical services to meet patients needs and reduce the demand on GPs. Small local changes have been able to happen quickly while large scale plans as part of the Cumbria Success Regime and developing a Cumbria-wide integrated care community have been worked on.

 

Among the new services introduced has been Listening Ear, which provides confidential listening to people’s problems and signposting to services which can address social and physicaliso lation, ranging from coffee mornings to mindfulness classes, dancing and Tai Chi. This has eased the pressure on GPs from patients who have social rather than clinical needs. Dressing clinics have been moved out of surgeries into the community, for example, to village halls and churches to make them more sociable events where isolated people can socialise. The council’s public health department has also employed health and wellbeing coaches to try to prevent childhood obesity and reduce the burden on health services.

 

Other projects include a review of patients receiving vitamin B12 injections, this found that only 20 of 66 people receiving them needed to, reducing appointments and district nurse visits. For patients with chronic obstructive pulmonary disease (COPD), the primary care home is moving services into the community so people will no longer need to travel to Carlisle. The PCH has introduced new technology to enable self monitoring of blood clotting for people with chronic disease, putting them in charge of their care and reducing the need for district nurses to visit.

 

Lessons learnt include that it has been hard to take forward all the desired changes while wide-ranging reforms to the organisation of services are underway.

 

PARTNERS

 

Cumbria Clinical Commissioning Group, North Cumbria University Hospitals NHS Trust, Cumbria Partnership Foundation Trust, Cumbria County Council (social services and public health), Cumbria Council for Voluntary Service, and the Bishop of Cumbria.

 

 

 

5. Aspire Integrated Rugeley (AIR)

 

OVERVIEW

 

Rugeley is an old mining town which has a population with a higher than average prevalence of long-term conditions. There is a lot of respiratory disease in adults who worked in the mines and a fair amount of health inequality locally. Two of the four GP practices used to be one large practice and are now working together again as part of the primary care home. The vision is for out-of-hospital care to be delivered locally to avoid unnecessary hospital admissions, to improve whole population health outcomes of the local community across all age groups and have a proactive, health and wellbeing agenda.

 

HOW THINGS ARE CHANGING

 

To cope with rising demand for urgent care, the primary care home has set up an overflow same-day appointment clinic with each of the four practices taking it in turns to host the afternoon clinics. As well as GPs, patients are being seen by advanced nurse practitioners, urgent care practitioners and physician associates. A community-based dressing clinic has been started to integrate community nurses into primary care and treat patients in a social setting where they meet others and receive falls prevention advice.

 

There is now a redesigned service with the community trust to support patients in a large care home, which had a historically high demand for GP visits. Under the new pathway, there is leadership support for care home managers and the home contacts an advanced nurse practitioner initially to discuss any concerns. The nurse practitioner then pulls in additional support when needed. Early indications are that this is working well and requests are falling.

 

Patients with long-term stable conditions are being supported with telehealth. Teams of experts from hospital, community and primary care offer clinics to patients in surgeries. This expert approach has been shown to work with 19 out of 20 patients with respiratory conditions who would have normally required admission.

 

The primary care home is working with the acute hospital on a whole population health programme involving schools, universities, Tesco and other big employers. The programme aims to raise awareness of health and care careers and become ambassadors and promoters of a healthy body and mind.

 

Lessons learnt include that the primary care home seems to resonate with GPs, working as a bigger team and giving them a degree of resilience makes it feel like it will work. It is hoped it will lead to better patient outcomes, improved health for the local population and a reduction of stress and overwork for GPs.

 

PARTNERS

 

Four GP practices (Aelfgar Surgery, Brereton Surgery, Horsefair Practice and Sandy Lane Surgery), GP First Federation, Staffordshire and Stoke-on-Trent Partnership NHS Trust, Cannock Chase Clinical Commissioning Group, University Hospitals of North Midlands NHS Trust and patient representative.

 

 

 

6. South Durham Health Community Interest Company (CIC)

 

OVERVIEW

 

Four practices have united with several providers around a new vision of care and are pioneering innovative new services for people with mental health, chronic pain and long term conditions. South Durham has high levels of unemployment, deprivation, mental illness and chronic disease. The primary care home offered a flexible model for the three large practices in Newton Aycliffe and a smaller practice in Shildon to collaborate with other partners to improve services and to work together better.

 

HOW THINGS ARE CHANGING

 

To address the high levels of adult male suicides and reduce the delays in accessing treatment, community psychiatric nurses (CPNs) are based in GP practices so patients with mental health needs can be directed to them immediately. Co-operation between the three Newton Aycliffe practices has meant the CPNs are treated as a shared resource and patients can be referred to whichever practice’s CPN can see them first. Shildon was the first to pilot CPNs being based at the surgery, this was then rolled out to the other practices (and across the clinical commission group) following positive evaluation. The move has generated positive feedback from patients and GPs.

 

Chronic pain had traditionally been treated in secondary care with medication. The primary care home has piloted an eight week course in mindfulness at its Shildon practice which is now being rolled out across the other practices.

 

The PCH has focussed on improving self-care for patients with diabetes through the Insignia Patient Activation Measure (PAM). The measure is used to rank patients at one of four levels of activation of care, patients at the lowest levels are being proactively referred to services that can support patients achieving lifestyle and behaviour change. Following a programme of tailored support, patients will be reassessed for a change in their activation measures. It is planned to incorporate the measure into patient annual reviews.

 

Lessons learnt include the need for everyone to be able to see they are having a positive impact. Staff need to feel welcomed as part of the practice team even if they only spend a limited amount of time there.

 

PARTNERS

 

Four practices, County Durham and Darlington NHS Foundation Trust (acute and community services), Durham County Council, Macmillan and other voluntary sector organisations.

 

 

 

7. The Healthy East Grinstead Partnership

 

OVERVIEW

 

The primary care home was established to improve the health of the population of East Grinstead and deliver a high quality local model of health and social care that is sustainable for future generations and works for children, families, people with increasing health needs and our older population. The town’s four GP practices had been struggling to recruit and cope with demand treating a population that was living longer with long-term conditions. They wanted to build on the strength of general practice. The PCH’s objectives are to enhance primary care, improve access and bring specialist care to the community.

 

HOW THINGS ARE CHANGING

 

The biggest initiative has been to merge the community nursing team and an existing multidisciplinary proactive care team (consisting of occupational therapists, physiotherapists, community psychiatric nurses, community matrons, and social workers) to create an enhanced primary care team to focus on patients at highest risk of admission to hospital and to provide care to stop unnecessary admissions. Patients are receiving more joined up care and are less likely to be admitted to hospital.

 

GPs are no longer involved in activities where they were adding no value, freeing them up for other work and improving access. These include the referral of pregnant women to midwife services (self-referral introduced), referral of people with musculoskeletal needs to a physiotherapist (self-referral introduced) and prescribing wound dressings (community nurses now order these online).

 

Care co-ordinators have been introduced at all four practices to signpost patients to non-clinical services they may need, ranging from food banks to social clubs. An additional urgent, on-the-day primary care service is being developed across all four and the PCH is working closely with the Fire Service to ensure housebound patients at risk of falls have their social and medical needs identified.

 

Lessons learnt include that the PCH needs a collaborative mindset from all organisations and a lot of one-to-one engagement. Buy-in comes from explaining specific changes and benefits to individuals and teams.

 

PARTNERS

 

Four GP practices, Horsham and Mid-Sussex Clinical Commissioning Group, Queen Victoria Hospital NHS Foundation Trust, Sussex Community NHS Foundation Trust, Sussex Partnership NHS Foundation Trust, East Grinstead Town Council, West Sussex County Council, South East Coast Ambulance NHS Trust, Age UK East Grinstead and District, St Catherine’s Hospice, Horsham and Mid-Sussex Voluntary Action, West Sussex Fire and Rescue Service.

 

 

 

8. St Austell Healthcare

 

OVERVIEW

 

St Austell has high levels of long-term unemployment and socio-economic deprivation as well as a high prevalence of chronic disease and obesity. The primary care home model offered a framework for one large practice to redesign services and offer new ones in partnership with a wide range of statutory and voluntary sector organisations. Its vision is to provide sustainable services to its patients, meeting unmet needs and enabling people to access non-clinical solutions.

 

HOW THINGS ARE CHANGING

 

The primary care home has established integrated, multidisciplinary teams and opened up access to many non-clinical activities which can address the wider determinants of ill-health. It has focussed on three key workstreams: social prescribing, integration of health and social care and workforce development. The result is better and new services, less duplication and more skills development for staff.

 

Many of the practice’s patients are the frail elderly who are physically inactive, often socially isolated and lonely.

 

Poverty and unemployment are also major challenges. The practice engaged with community providers, employing a social prescribing facilitator who sees patients and refers them to resources ranging from walking groups to Zumba, pilates classes and a canoe club, to increase their physical activity, improve their diet and reduce isolation. The pilot resulted in 52 out of 150 patients completing 12 weeks of the programme, of those 94% saw an increase in their wellbeing score and 62% had lost weight.

 

An integration manager role has been created to improve hospital discharges, the treatment of complex patients and palliative care. Home visits are being managed better and duplication has been reduced. GPs had been making 30 home visits a day but many patients were also being visited by district nurses, community matrons and the mental health team. Community nurses and district nurses have also been co-located at the practice’s acute hub which sees urgent same-day cases.

 

The PCH has concentrated on skills development for staff and diversifying the multidisciplinary team. A pharmacist is part of the practice team carrying out medication reviews. There is a nurse-led minor illness team, with the team internally trained and an acute visiting service using emergency care practitioners.

 

Lessons learnt: It takes time to build the relationships between organisations needed to make this work. Time to lead is essential.

 

PARTNERS

 

Kernow Clinical Commissioning Group, Cornwall Partnership Foundation NHS Trust (community and mental health trust), Cornwall County Council, St Austell Town Council, the Eden Project, Public Health England, Age UK, Pentreath (a mental health charity) and some big local employers including St Austell Brewery.

 

 

 

9. Thanet Health Community Interest Company (CIC)

 

 OVERVIEW

 

 

Demand for health services has historically been high in Thanet with an elderly population and deep pockets of deprivation. Forty per cent of the population is over 60 and many are frail in their 50s. At the same time, primary care has faced recruitment problems, with GP practices closing and those surviving struggling to cope with huge pressures on existing staff. With better prevention, there were indications that cardiovascular, respiratory disease and cancer could be diagnosed sooner.

 

HOW THINGS ARE CHANGING

 

There was a collective realisation that the status quo was unsustainable for patients and staff. Health and social care organisations realised that they needed to come together to pool resources on a voluntary basis to start building an integrated, accountable care organisation to improve care for frail elderly people and reduce demand. An integrated nursing team was established to provide an enhanced frailty pathway and an acute response team created to provide a range of treatment and personal care support to keep people out of hospital.

 

The team comprising a GP, nurses, health care assistants, physiotherapist, occupational therapist, voluntary care, care agency work closely with social services. They assess patients and put a package of care in place to enable them to remain at home or be discharged. Heath and social care coordinators were also brought in to GP surgeries to provide non-clinical support to patients and GP surgery hours extended to include weekends and Bank Holidays.

 

The frail elderly are receiving better care out of hospital and being admitted to hospital less frequently. Over a 10-week trial period in 2016/17, non-elective admissions fell by 155 compared to the same period last year, suggesting potential annual savings of almost £300,000.

 

Medication reviews have also brought down prescribing costs.

 

Factors contributing to its early success have been the commitment and buy-in from all organisations involved, effective staff engagement, commitment and leadership from the clinical commissioning group. Continuing funding of initiatives or an adequate capitated unified budget for the PCH will make it stick.

 

PARTNERS

 

Four practices, Kent Community Hospital Foundation Trust, East Kent Hospitals University Foundation Trust, Kent County Council (social care), Kent and Medway Partnership Trust (mental health), Ageless Thanet, voluntary sector organisations including Age UK and Crossroads, Local Pharmaceutical Committee, Local Dental Committee, Local Ophthalmic Committee, Thanet Hospice, South East Coast Ambulance Service.

 

 

 

10. Wolverhampton Total Health

 

OVERVIEW

 

The primary care home has helped to stabilise and unite a group of eight GP practices struggling to deliver services in an area of high need, and develop new services focussing on the frail elderly, access and diabetics. Small GP practices were struggling with severe health inequalities together with an uneven distribution of frail elderly and diabetic populations which skewed demand. They were struggling to recruit staff and lacked the scale to bid for additional funding. It was clear that greater integration was needed to create a sustainable basis for providing specialist multidisciplinary care which in turn would reduce demand on health and care services.

 

HOW THINGS ARE CHANGING

 

An integrated multidisciplinary team has been created to run severe frailty clinics focussing on care and prevention for the frail elderly. The team consists of a health care assistant and a senior clinical pharmacist. Each patient has a complete geriatric assessment covering mobility, exercise, hearing, vision, incontinence, medication review and lying and standing blood pressure (a good predictor of falls risk). The PCH has also linked up with the Fire Service who make ‘safe and well’ visits to people who have recently fallen.

 

A virtual diabetic clinic and an insulin initiation service have been launched, with support from pharmaceutical companies, to speed up increased medication for poorly controlled diabetics and reduce the need to refer into the hospital clinics. Run by a specialist diabetic nurse and GP, the clinic offers advice while practitioners see patients in their surgeries.

 

The scale of the PCH has enabled it to bid for funds for additional services which individual surgeries were too small to bid for. Winter pressure money has been used to run additional surgeries over the Christmas bank holidays and Saturday mornings. These are held with the second primary care home in Wolverhampton with three practices acting as hubs in the city to cater for their combined 100,000 patients.

 

The EMIS IT systems from all practices have linked up enabling the hubs to access a patient’s full records provided they give consent.

 

The PCH has been involved in running several pilots to help the clinical commissioning group (CCG) look at new services. In-house counsellors have been introduced following a bid for additional CCG money and social prescribing clinics funded by the city council. Both have proved successful.

 

Lessons learnt include that establishing a PCH takes much time and commitment – the GP lead is paid four hours a week to support it but spends two days a week on the PCH.

 

PARTNERS

 

Wolverhampton Total Health (eight practices: Newbridge Surgery, Whitmore Reans Health Centre, Fordhouse Medical Centre, Tudor Medical Practice, Church Street Surgery, Caerleon Surgery, East Park Practice, Keats Grove Surgery), Wolverhampton Clinical Commissioning Group, the local authority’s public health team, Refugee and Migrant Centre, West Midlands Fire Service, Royal Wolverhampton NHS Trust.

 

 

 

11. Winsford Group

 

OVERVIEW

 

Winsford, one of the most deprived areas in the country, has improved population outcomes with a town-based approach to health and wellbeing. When it applied to become a primary care home rapid test site, it had the worst one-year survival rates for cancer in the country. As a primary care home with a population size of 33,000, the group was able to focus on the whole town to improve both population health and clinical outcomes. It also gave practices the opportunity to be at the heart of service redesign shaping the priorities and changes needed.

 

HOW THINGS ARE CHANGING

 

There is a much stronger partnership approach to improving the health and wellbeing of the local population with clinicians stepping forward to lead improvement areas. The primary care home covers five programmes: prioritising to meet local needs, patient empowerment and resilience, right services, right place, right time, primary care sustainability and transformation and preparing for accountable care.

 

The primary care home brought together the key stakeholders to discuss poor cancer outcomes and whole population health in Winsford. This led to the idea of lung cancer awareness being included in the annual town council’s wellbeing week. During the week, GPs, practice staff and voluntary sector representatives informed the community about lung cancer and respiratory health. It signposted people to information on asbestos, undertook respiratory function tests, encouraged them to seek early advice if they had concerns and, if necessary, people had direct access to chest x-rays without the need to see their own GP first.

 

Winsford no longer has the lowest one-year survival rates in the country. While this cannot be directly accredited to the PCH, it was the vehicle that enabled the focus on respiratory health, the actions that followed, and to look at best practice from other areas.

 

Lessons learnt include that working in partnership on a town basis delivers a stronger population health and well-being focus, the need to have a dedicated GP lead, it is vital to have good data to tell a compelling story and being careful with language and approach, for example, using the term lung health and not lung cancer.

 

PARTNERS

 

Five practices, Vale Royal Clinical Commissioning Group, stakeholders and partners through the Connecting Care Provider board.

 

 

 

12. Beacon Medical Group

 

OVERVIEW

 

The Beacon Medical Group in Plymouth – a very large practice across five sites - was frustrated with the fragmentation and dilution of local services and increasingly distant relationships with other health and care agents. It was also caring for patients with complex care needs in the face of a rising workload. There was high demand for appointments which didn’t need GP expertise, staff were overworked and suboptimal working with other partners.

 

Taking on the mantle of a rapid test site enabled it to innovate in many ways, improve services to patients, address unmet needs and transform relationships with other providers. Its vision has been to create an integrated health and wellbeing service which meets its population’s needs and inspired its staff.

 

HOW THINGS ARE CHANGING

 

Beacon Medical Group has cut the average waiting times for GP appointments by six days by expanding its urgent care teams across its sites. The teams comprising one or two GPs, a paramedic, nurse practitioners and pharmacists screen all patients seeking on-the-day appointments on the phone and invite those who need to be seen in. Over six months, the average waiting time for a GP appointment fell from 14 to eight days.

 

There is an enhanced service for the six largest care homes in their area. Each week a pharmacist and a GP carry out a ‘ward round’ at each care home visiting patients who are most at risk of hospital admission. They provide support to care home staff to help them support the patient better. The pharmacist conducts medication reviews to reduce the complexity and cost of medication where appropriate. The PCH has also refocussed its virtual ward, a monthly multidisciplinary team meeting involving the voluntary sector, physiotherapists, mental health staff and the community health team, who discuss patients they’re concerned about, mainly the frail over-50s, create treatment plans and monitor progress.

 

Research into its most high-intensity patients, who had the most contact with GPs found that often they had mental health needs which were not being treated and they were going to A&E, sometimes with unexplained physical symptoms. A liaison psychiatrist from Devon Partnership Trust is now based in surgeries two days a week to see patients and offer advice to GPs.

 

More services have been started for vulnerable groups. For young people a ‘takeover day’ was held encouraging them to redesign services and counselling introduced in the evenings. There are many armed forces veterans in the area who are vulnerable to mental health issues, diabetes, tinnitus and musculoskeletal problems. By running a campaign, the PCH now knows of some 90 veterans locally and can offer them greater support.

 

Beacon are working with community pharmacists on marketing campaigns around flu jabs, using media and social media and messaging on prescriptions to target those most in need. Lessons learnt include a willingness to take risks and take on new initiatives without waiting for full funding to drive visible change.

 

PARTNERS

 

Beacon Medical Practice, Plymouth Hospitals NHS Trust, Devon Partnership NHS Trust (mental health), LiveWell SouthWest (community services), South Hams Community and Voluntary Services, Plymouth Octopus Project (support network for voluntary sector), Local Pharmaceutical Committee, New Devon CCG, Plymouth City Council.

 

 

 

13. Luton Primary Care Cluster

 

OVERVIEW

 

Cambridgeshire Community Services NHS Trust and two GP clusters came together to design and deliver services targeting groups in the community with significant needs. They focused on older people with multiple medications and patients with type 2 diabetes. The primary care home model was a flexible solution which enabled them to collaborate and deliver services in a way which met the needs of their patients and their organisations.

 

HOW THINGS ARE CHANGING

 

The rapid test site were aware of increased use of medications in the elderly population and concerned about the adverse outcomes, such as hospital admissions and falls which can be associated with polypharmacy. With limited resources, Medics United cluster looked at how they could work differently to support patients, particularly those over 75 years taking ten or more medications. Using funding as a rapid test site, they employed a clinical pharmacist for a 12-week pilot (September to December 2016) who visited surgeries and housebound patients, explaining and reviewing their medication in a one-hour consultation, reviewing their adherence to their medication and assessing their risk of developing an adverse drug reaction or admission to hospital. Since the pilot, community pharmacy technicians have followed up with patients and monitored the impact of the reviews.

 

Luton’s population has a high prevalence of diabetes. Many primary care colleagues had highlighted that their type 2 diabetes patients were not understanding fully the condition and this was leading to complications. Kingsway cluster targeted patients who were struggling to self-manage their condition with a HBA1C score of more than 80 (levels of glycated haemoglobin indicating average blood sugar levels) with repeated failures to attend GP, retinopathy or podiatry appointments. Patients were asked to attend specialist clinics for a one-hour consultation with the community diabetes team (clinics in Urdo, Bengali and English). The team discussed with patients how they were managing their condition and used the Patient Activation Measure (PAMs) to tailor their approach to supporting and motivating them. After the appointment, patients can attend weekly group sessions for four weeks giving them an opportunity to share experiences and information, learn more about diabetes and living with a lifelong condition, support other attendees and make new friends. The rapid test site is in the process of piloting this pathway, so no evaluation is available.

 

Lessons learnt include that engagement with all stakeholders is key in the design, planning and implementation of the pilots.

 

PARTNERS

 

Nine practices (Barton Hills Medical Group, Bell House Medical Centre, Woodland Avenue Practice, Gardenia and Marsh Farm Practice, Kingsway Health Centre, Pastures Way Surgery, Conway Medical Centre, Medina Medical Centre and Wenlock Surgery), Cambridgeshire Community Services Trust, Luton Clinical Commissioning Group, patient groups, Healthwatch and LiveWell Luton.

 

 

 

14. Richmond

 

OVERVIEW

 

Covering Twickenham and Whitton, Richmond Primary Care Home has a large population in a busy London borough. Its vision has been to work with front line staff to help identify the needs of the frail and elderly across Twickenham and Whitton and to work with multidisciplinary teams to strengthen best practice, identify gaps and introduce innovation.

 

It has brought together different workforces to care better for the frail and elderly, and listened to its local community, leading to frontline signposting training and engaging local college students in a mentorship training programme at a local care home.

 

HOW THINGS ARE CHANGING

 

Richmond held a series of learning workshops with multidisciplinary teams and spoke to all the practices, community pharmacies, community providers and therapists gathering best practice, areas for improvement and gaps in provision. These confirmed that carers were a vital part of health and social care and they needed better links into the health care system to both primary and community care. With an estimated 25 per cent of GP appointments not needing a GP, the PCH delivered level one signposting training to receptionists and pharmacy counter assistants to assess the type of help needed for people to stay well and maintain independence. This is being evaluated to help shape future training.

 

The PCH has launched a nursing home carer mentor scheme after raising awareness to health and social care students at Richmond College of Further Education about careers in the health and care sector and improve their prospects. Under the carer mentor scheme, students received an induction and then attended the nursing home once a week for six weeks working alongside staff for a full working day. Each student was allocated a mentor and they were able to gain experience of what the job entailed.

 

There are plans to roll out an emergency transfer scheme (‘red bag’) aimed at supporting accurate assessment and transfer to hospital from care homes. The "red bag" keeps important information about a care home resident's health, including existing conditions and medication, in one place, easily accessible for ambulance and hospital staff. This means that ambulance and hospital staff can determine the treatment they need more effectively. This clearly identifies a patient as being a care home resident which means it may be possible for the patient to be discharged sooner.

 

Lessons learnt included that engaging and listening to front line staff and supporting them will increase the sustainability of this programme.

 

PARTNERS

 

Eleven practices, Hounslow and Richmond Community Healthcare, Richmond Clinical Commissioning Group, independent care homes, Richmond GP Alliance and the Richmond Local Pharmacy Committee, voluntary organisations.