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Letters Spotlight: Patient Centred Care

How can we get better at providing patient centred care: does continuity matter?

BMJ 2015; 350 doi: (Published 10 March 2015) Cite this as: BMJ 2015;350:h1127

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Can micro-teams offer better continuity for multimorbidity in Tower Hamlets?

Tower Hamlets Clinical Commissioning Group (CCG) clinical leads engaged with primary care to explore definitions of excellence in general practice, barriers to delivery, and visions for future care. ‘Unhealthy perfectionism’ was a persistent theme and when combined with GPs who had an external locus of control there was overwhelming pessimism and isolation consistent with national figures that show more than 50% of GPs suffer burnout. However, some GPs expressed positive attitudes identifying collaboration as a solution. A key theme in this group was personal, team, and system resilience. Other themes emerged and included restoring continuity of relationship with patients and also restoring 'ownership and control' especially amongst sessional GPs.

Expert generalist care is urgently needed for people with multi-morbidity. The response to this challenge in Tower Hamlets is ‘integrated care’ led by the Clinical Commissioning Group, with the aim of improving horizontal and vertical integration between all health and social care providers. This Person Centred Integrated Care package is being delivered through a CCG Network Improved Service to people who are identified as having complex needs, via the eight networks which encompass the 36 practices delivering care to the 280 000 residents of Tower Hamlets

Evidence suggests that continuity of care is crucial to people living with multiple long term conditions so that care can be both provided and experienced as connected and coherent. Loss of all forms of continuity, in the drive for access and cost saving, together with an increasingly portfolio workforce (>70% of Tower Hamlets GPs are Sessional GPS), is affecting quality of care. Local audits in two large, high QOF performing practices showed poor continuity of relationships with GPs. The first showed delays in cancer diagnosis, with over eight GPs on average being seen in the year before diagnosis. The second, an audit of care in the year before death in hospital, showed that patients saw a similar number of GPs to the above. The increase in part-time working means that formal systems to share care between clinicians are essential to improve the continuity needed to manage complexity well, both for the satisfaction of patients and staff.

We aim to deliver better person-centred care for those living with multi-morbidity through the development of highly functional micro-teams ('teams within teams') in general practice. We hypothesise that a team approach in primary care will make a difference to people living with multiple life limiting conditions and also to staff providing care. A secondary hypothesis is that if practices are starting to rationalise ‘back room functions’ then micro-teams maybe the beginning of restoring 'ownership and control' i.e.front room function’

Five large practices (ranging 9964-12485 registered patients) responded to an invitation in June 2014, to support the introduction of micro-teams. One of the practices had already established a ‘buddy’ system but wished to develop this further. Practices were free to define their own team model and could include a range of professionals with different skills, such as the GP, nurse, healthcare assistant, social care worker and patient advocate, or other professionals.

We aim to evaluate the impact and challenges of micro-teams in our setting of high social disadvantage. Individual practices have defined their model to match their unique circumstances, each will complete at baseline, a solution focused description of the opportunities, challenges and possible measurable benefits of establishing micro-teams.

Other outcome measures to be completed at baseline, midway and one year from implementation are:
1. Staff: A self reported measure of each team 
member’s sense of personal achievement adapted 
from the Maslach Burnout Inventory 

2. Patients: A sample of patients identified from the 
Person Centred Integrated Care Network Improved Service to complete a questionnaire adapted from Haggerty and Freeman’s generic tool measuring continuity. 

3. Team effectiveness: teams to complete a team development tool measuring the four domains of highly functional teams: cohesiveness, communication; roles and goals; team primacy. 

Competing interests: No competing interests

16 March 2015
Naureen Bhatti2, George K. Freeman32 GP Limehouse Practice, Tower Hamlets, Associate Dean, Professional Support Unit, London
3 Emeritus Professor of General Practice, Imperial College London
GP Clinical Lead Last Years of Life and Primary Care Quality
NHS Tower Hamlets Clinical Commissioning Group 2nd Floor Alderney Building Mile End Hospital Bancroft Road London E1 4DG