Primary care teamBMJ 2016; 353 doi: https://doi.org/10.1136/bmj.i1842 (Published 07 April 2016) Cite this as: BMJ 2016;353:i1842
Kaysia Heafield, a general practitioner at Somercotes Medical Centre in Derbyshire, recalls the day when she was faced with a patient with arthritis so disabling she needed crutches to walk. “She said she was a carer for her mother, and had been also for her father, who had died. I was trying to understand what she needed. I said I could put her on the carers’ register and she said, ‘What will that mean to me?’ She didn’t want outside carers to come in. She enjoyed looking after her parents; it was a pleasure. She just needed support.”
Heafield ran a survey of her patients and found many carers who felt stressed, undersupported, and short of practical help. She rang Derbyshire Carers’ Association, a local charity, and suggested a partnership that involved locating one of the charity’s carer support workers in the surgery.
“They find it really difficult to get to carers—they can’t identify them easily. Now they have a room in the surgery, they can do their job in a much more efficient way. We can send patients to the next room, and that feels better. It’s no longer passing the buck. She can help them by tapping into benefits, respite care, disability badges, whatever they need.” Regular clinics are held and are accessible to all carers, not only those who are patients of the practice.
Responses have been strongly favourable, with a lot of positive feedback. GPs at the practice have become better at identifying carers and now feel there is something to offer them. The project is cost neutral so should be sustainable. The clinical commissioning group is now supporting the integration of care support workers into 17 other general practices in Derbyshire.
Bradford respite intermediate care support service
Bevan Healthcare, a community interest company in Bradford, is contracted to provide primary care to homeless people, refugees, asylum seekers, and those living in temporary accommodation—a vulnerable group often missed by primary care services designed for people who lead more settled lives. It has 3600 patients and a steadily growing list.
Gina Rowlands, managing director of the company, says that emergency department attendances and admissions are much higher for this group than for the population as a whole, and for homeless people death comes early—at an average age of 47 for men and 41 for women. Many spend time in hospital only to be discharged to their “usual place of residence”—the street.
In a partnership with Horton Housing Association, Bevan in 2013 opened a 14 bed unit designed for homeless patients who had continuing healthcare needs on discharge. “It’s a holistic model, providing both health and housing needs,” Rowlands explains. “There are 14 self contained units, staffed 24 hours a day, and we provide a GP and a mental health and substance misuse nurse. The average length of stay is five to six weeks, but some stay longer.” The average cost of a stay is £5633 (€7100; $8100), but average secondary care costs for those helped are estimated to have been reduced from £46 800 to £11 000.
“When they’re ready we move them on to sheltered housing or supported accommodation,” she says. “Some have gone back into employment and some who have never accessed education have gone to college. Some of our best outcomes have been end of life, where patients have been able to move on to a hospice and have the death they deserve after a very difficult life.”
Community based deep vein thrombosis service
Deep vein thrombosis (DVT) is confirmed in around 1 in 1000 people a year in the UK but wrongly suspected in many more. Of 425 000 suspected cases a year (285 000 of which present in primary care) just 64 000 are confirmed after Doppler compression ultrasonography.
“These suspected cases, on the whole, get referred by GPs to hospital,” says Andrew Hughes, consultant community haematologist in north east London. “You know what it’s like if you have to go to hospital, particularly if you’re an elderly patient. It’s a pain to get there, you’ve got to park, then you have to wait, then you meet a variable degree of expertise. Then there’s often a delay in getting a scan done, and if they have got a DVT they have to go constantly back to the hospital clinic to get their anticoagulants done.”
His answer is a local service based in Brentwood Community Hospital, which already had a small radiology suite. Recently retired, Hughes went back to work to run the service with nursing staff. They found that many scans gave negative results and reintroduced an older tool, strain gauge plethysmography, on a trial basis. “To my surprise it was extremely good, able safely to exclude many more people from Doppler scanning,” he says. “That meant for the patients who needed scans we could offer them the same day or the next day.”
Patients found not to have DVT are routinely followed up three months later, showing a diagnostic failure rate of less than 0.5%. “The service is local, high quality, and much less costly—£75-£100 per patient compared with £300,” he says. “It’s a model that would work nationally.”
Healthy living project
Elderly people living independently want above all to keep it that way, says Jane Harvey, a GP in Hyde, a poor area of Greater Manchester. But they get little help to do so, being largely invisible until a health crisis intervenes. Then they are often admitted inappropriately to hospital, triggering a complex combination of health and social care needs with which services cannot easily cope.
The solution, she believes, is to prevent the crisis by intervening earlier to preserve the autonomy and resilience of people aged over 75. Using money from the Better Care Fund, her practice got together with others to identify and stratify over 75 year olds into three risk groups: low, medium, and high. “The low risk group were sent a follow-up letter about the project, the middle risk group had a few visits to offer support and information, but the high risk group had intensive intervention,” she says.
“We were trying to create what they really felt they needed. There were a lot of social interventions and some medical referrals. Some interventions were really simple. We found one man who’d had falls who was worried about getting his dustbins in and out of his drive for emptying. Actually you can apply to have it done by the dustbin men, but he didn’t know that, and you have to apply online, which can be difficult for elderly people. Another simple intervention was reducing nuisance phone calls by telling people about the telephone preference service.”
Challenges included gaining the confidence of what she calls “a very self sufficient and stoical generation.” But results were encouraging, with 60% of the high risk group reporting improvements in their quality of life. More was recouped in unclaimed benefits than the project cost.
Kendal care home pilot
Kendal in Cumbria is a small town with eight residential and nursing care homes. “The area is very attractive to retired professionals, and as their health declines they need care, and all the beds seem to be in Kendal,” says Alison Nicholson, a nurse practitioner. Providing primary care to the 440 beds the town now provides was a challenge to the three general practices, which decided to combine forces to plan a response.
Funding was found from the clinical care group to recruit a full time nurse practitioner (Nicholson) supported by pharmacists and a dietitian. “We were very proactive,” she says. “Initially we worked for a block of time in each of the homes, depending on the size, either two weeks or up to five weeks, until we’d met all the residents and their families, and made baseline assessments of all those residents.
“Then it evolved. We’ve got three big nursing homes, and we do a day a week in each, and five residential homes, and they get half a day every other week.”
Results include a reduction in emergency department attendances and non-elective hospital admissions, medication savings in 2015 of £60 000, and a decrease in the number of residents being transferred to hospital at the end of life. The quality of care has improved, and staff at the homes are very supportive. “It’s more personal. They come in, they know who they are talking about—it’s just nice to know they know a little bit about each one of our residents,” was one comment the team noted.
Overall the project was cost neutral, its annual budget of £108 000 matched by savings elsewhere.
The Primary Care Team of the Year award is sponsored by MDDUS. The awards ceremony takes place on Thursday 5 May at the Park Plaza Hotel, Westminster. To find out more go to thebmjawards.com.