Seven GP practices visit a large number of different nursing and residential homes to deliver flu vaccines to patients, this means some homes receive visits from multiple nurses. This was considered inefficient and a challenge was identified to work more effectively.
www.exeterprimarycare.co.uk @EPC_exeter
Patients were experiencing difficulties attending the GP surgery during the working week and were presenting at the emergency department, Devon Docs, the Walk in Centre and contacting 111.
The staff at the 16 Exeter Primary Care general practices designed an Enhanced GP Access scheme to benefit their patients.
Jo has been a GP in Crediton
for a number of years and over the past two years in particular has
demonstrated a passion to embrace the changing primary care landscape, innovate
and drive change in order to develop a sustainable model of primary care that
works well for patients, practices in her federation and the wider system.
Jo is very cognisant of the
issues facing primary care – in particular she exhibits a desire to solve the
key issues of workforce, recruitment and sustainability by being innovative.
She is particularly enthusiastic about de-medicalising issues and involving the
voluntary sector in helping with this.
She speaks passionately about the need for
change and her enthusiasm is infectious to those that come into contact with
her.
In South Somerset, in common with many parts of the South
West, we faced the linked problems of soaring demand for healthcare and rising
costs at the same time as a staffing crisis in general practice and other parts
of the system. The Symphony Programme
was set up in response to this as a collaboration between South Somerset GP
Federation (19 practices), Yeovil District Hospital, Somerset Partnership NHS
Foundation Trust and Somerset County Council. It is led by a Programme Board which is
chaired by a GP and includes four elected representatives from primary care (3
GPs and a practice manager partner) as well as the GP Associate Medical
Director of Yeovil Hospital, who is also a local GP. Yeovil Hospital has four representatives
including the Chief Executive, and there are also representatives from Somerset
Partnership, Adult Social Care, the voluntary sector and Somerset CCG.
There is a small programme team hosted by Yeovil Hospital led by a dedicated Programme Director and we are one of the nine national Primary and Acute Care System (PACS) Vanguard sites. Other parts of the programme have focussed on developing new organisational forms: one to support primary care (Symphony Healthcare Services has been established as a subsidiary of Yeovil Hospital to allow practices to integrate where they wish to); and another to hold a capitated, long term outcomes based contract for the whole population in a joint venture between primary care, Yeovil Hospital and other partners.
Together we have analysed our population, joined up the data, developed new integrated care models and new organisational forms to support primary care.
The
capacity to cope with the workload pressures in primary care have been
fundamental influences in
integrating the community pharmacist
into the surgery team to facilitate the adoption of the Five Year Forward View.
In August 2014 the largest practice in St Austell (Polkyth) handed back their GMS contract, leaving 8,000 patients without a GPs. Polkyth’s failure put significant pressure on the remaining 3 practices in the town. Those practices joined together to run Polkyth for 12 months and then, following a public consultation merged all 4 practices. We have redesigned Primary Care services for our 32,000 patients with an emphasis of upskilling our broad MDT, collaborative working with our community (NHS and non-NHS) partners, with our acute trust and OOH provider. We have improved access by running an acute-care hub from the old Polkyth site (open 8-8 Monday to Friday).
The merger has saved primary care in St Austell from likely collapse. We believe that we now have a sustainable clinical and financial model that meets the demands on current primary care and is dynamic enough to embrace future change.
Our innovative approach and ability to implement change has
been recognised by the NAPC and we are currently one of 15 national test sites
for the Primary Care Home Pilot.
- GP shortages resulting in recruitment difficulties due to the national
shortage of GPs
- Providing an adequate and appropriate level of same day appointments to
meet patient needs
- The requirement for improved advanced appointment availability, both in
general and with patients’ usual GP
- The need to increase patient self-care
- Appropriateness of care – enabling patients to be seen by the most
appropriate clinician, who may not always be a GP
- GP dependence – educating patients and exposing them to other
provisions within the practice and community that are able to best meet their
needs
As highlighted in the GPFV we are currently in a workforce
crisis. Demand has steadily increased
over the past 10 years and the GP workforce has been unable to increase to
provide the capacity. Over 300 million
consultations occur in Primary Care every year. As a practice with our growth we were aware
after partaking in the NHS Productive GP Programme that 50% of our demand at
our largest site was “On the Day Demand.” The problem was how to meet this demand and insure that the right care
could be given by the right person at the right time working in a financially
sustainable model with the workforce available in the locality.
As a practice we are not afraid to look at the service we provide for our patients and ask could it be done better and if so how. We are very aware that we need to release capacity in primary care to deal with the rising levels of medical complexity but also recognise that the model needs to financially sound to stabilise General Practice in our local community.
Pill checks and asthma checks were provided in practice,
requiring patients to attend and sometimes present very little or no change to
their condition taking a GP appointment which is sometimes time pressured. We
developed streamlined self-care systems
to improve the pathway.
General Practice, with its registered list and
everyone having access to a family doctor, is one of the great strengths of the
NHS, but it is under severe strain. Even
as demand is rising, the number of people choosing to become a GP is not
keeping pace with the growth in funded training posts. General practice must work as one with other
key partners to address the sustainability and quality issues.
We must:
- Develop a primary care infrastructure to
support new models of care
- Enhance access to primary care weekends and
evenings through use of technology
- Build multi-disciplinary teams to underpin new
models of care ensuring integration with other service providers
- Develop, retrain and train our workforce so
that it has the right skills, values and behaviours in sufficient numbers and
the right location to deliver the new models of care
Pioneer Medical Group is uniquely placed to
develop a new model of care for our population which addresses the points above
and is both expansionist and sustainable.
Patients
in Nursing and Residential Homes are currently underserved within the current
General Practice Contract. GP care to
residents in Nursing and Residential Homes is often limited to visits on
request, (reactive) with little continuity of care and each care home usually
has residents registered with a variety of GP practices leading to fragmented
inconsistent care. In
addition, polypharmacy is often one of the main causes of emergency admissions. Adverse
Drug Events account for approximately 6.5% of all hospital admissions, but more
in older people, leading to increased hospital stay and significant morbidity
and mortality.
Evidence
shows that care home residents are among the most vulnerable people in our
society with complex needs that often include multiple long term conditions and
advanced frailty which cannot be met by primary care within the GMS contract to
the level required to ensure good quality of care.
Care home residents are unable to attend their local pharmacy for treatment of minor ailments, or attend their primary care practice, resulting in frequent visits to the care home with frequent and multiple prescribing interventions. They also have a higher than average use of emergency and urgent care services, including SWAST and Devon Doctors.
We propose a change that challenges the current model, which recognises the vulnerability and heightened medical risk for this frail group of patients.
The rural nature of the practice
and changes to the traditional model of family support where grandparents,
parents and children are less likely to live within the same community means
that patients accessing surgery services can be vulnerable and socially
isolated. This impacts on the health and wellbeing of patients but capacity to
deal with what may be considered social issues as well as navigate the social
care system is limited and is outside the traditional GP contract model.
A number of challenges are identified by the NHS England General Practice Forward View that we are looking to address:
- GP workload
- GP burnout
- Access to healthcare
- Recruitment and skill mix
- Aging and growing long term condition population
- Increase in demand
- Patient expectation and expectation management
- Person centred care
- Self-management and taking responsibility for our own health
In February 2016 our GPs were completely overstretched with patient demand which was impacting the entire practice and patients alike.Demand had increased 10% on the previous year and we were constrained within our tight financial envelope. We did not have any Nurse Practitioners or Minor Illness nurses working within our team.