SIX GP practices in Cumbria have teamed up to use new ways of working together to deliver safer and more personalised community care to their patients, as part of a national NHS drive.
Primary Care Home is a new national NHS community model which allows small groups of practices, covering populations of approximately 30,000 to 50,000 patients, to work together to take responsibility for a capitated budget.
The aim is to allow the development of community-based services that are more patient focused and less reliant on hospital care.
Cumbria Primary Care Home is made up of six practices with a combined patient population in excess of 50,000 patients, including Maryport Group Practice in Maryport, Derwent House Surgery and Castlegate Surgery in Cockermouth, Temple Sowerby Medical Practice, Kirkoswald Surgery, and Birbeck Medical Group in Penrith and Appleby Medical Practice, in Appleby Westmorland.
Parts of the region face many widely reported health challenges within the local population which include, to the West of the county, high levels of obesity in children and deprivation caused by high levels of unemployment. Moving inland Cumbria moves to the other end of the spectrum becoming more rural, sparsely populated, generally more elderly and wealthier, bringing patients with more complex conditions.
Cumbria beat competition from over 70 applicants to become one of only 15 bids nationally to win the opportunity to become a pilot or rapid test site - for Primary Care Home thanks to support and advice from Scott McKenzie through medical accountancy firm BW Medical Accountants.
Susan Cousins is practice manager of Maryport GP practice, and a key member of Cumbria Primary Care Home, with over 20 years of experience in healthcare.
“In a community with some particularly pressing demands around healthcare services we were delighted to be among the first given the opportunity to implement this new pilot and the support and advice we received from Scott McKenzie via BW Medical Accountants was invaluable to our success which will only benefit patients,” she said.
“It is a way of working that is much more focused on the individual patient and results in a more effective level of communication between health and social workers which is key to giving patients timely care.”
Scott McKenzie, NHS Consultant & GP Federation expert of BW Medical Accountants, worked closely with Sarah Cousins and GP Dr Helen Jervis in helping to set up the structures and policies around Cumbria Primary Care Home.
“There is no doubt that the six practices working together are breaking new ground by focusing on new ways of working with their patients in the community to achieve the very best healthcare for them,” he said.
Under Cumbria Primary Care Home a multi-skilled team will be drawn from primary, secondary and social care to bring key professionals together to work with patients. This includes specialist practice nurses, community nurses and GPs from primary care, specialist hospital consultants who often project manage the team, and social workers from the local authority and voluntary organisations.
Cumbria Primary Care Home will provide a paediatric nurse or an elderly care consultant to head up the multi-skilled team to coordinate care around individual patients.
“In specific cases the consultant has made a home visit if the patient is unable to attend the practice. For the more vulnerable members of our community such as the elderly or the very young this has improved outcomes significantly and also reduced hospital admissions which of course reduces the pressure on hospitals and NHS services in general.
“It has also enabled us to build on our previous work around integrated care which saw us implement significant savings in delivering pediatric care over a 12 month period in a specific practice.”
The new ways of working take a more holistic approach to patients and it is intended that this approach will be rolled out across Cumbria Primary Care Home.
“Rather than treating patients as they present themselves with a specific issue and having an inherently reactive approach to their care; we are asking questions much earlier around each individual patient’s support networks and underlying issues.
“This information is then effectively communicated between all the different interested parties and a healthcare plan is devised and wrapped around the patient to address their particular needs.”
She added: “At the most basic level this means the patient is not having to repeat themselves but also means that healthcare is delivered far more efficiently with duplication of resources between different community organisations and healthcare providers largely avoided.”
National Association of Primary Care president Dr James Kingsland, an advisor to the Government on primary care, said: “The benefits of integrated care and multidisciplinary team working to provide comprehensive and personalised care to individuals and populations are well recognised.
“We believe this programme presents a unique opportunity for primary care to improve the quality of care provided to our registered patient populations and deliver better value for the NHS.”