BMJ Awards 2019: Primary Care Team of the Year

Novel approach to opiate use

Station Practice in Hastings developed a novel, holistic model of care to wean patients with chronic pain off opiates when they identified a problem with opiate prescriptions. “We were finding people who had been parked on fentanyl patches or industrial levels of opiates for decades. They now feel they’ve got their lives back,” says GP Anthony Dann.

The practice identified over 350 patients with chronic pain who had been on high doses of oxycodone, buprenorphine, or fentanyl for more than three months. “We explained that their pain system has become dysfunctional and the opiates are actually making things worse,” says Dann. The team developed resources to get patients on board, including a 12 step chronic pain tool kit and a self help group led by a motivational worker.

“We found we didn’t need to change patients onto other drugs such as gabapentin or tricyclics,” says Dann. “Listening to the patient’s pain journey had the most profound impact, followed by social work support such as with benefits or debt.” The practice also ensured that any anxiety or depression was diagnosed and treatment for any comorbidity was optimised.

Since starting the service in March 2018, 40 patients have stopped using opiates with a further 120 in the process of being weaned off the drugs. They have also seen a significant improvement in patients’ quality of life, pain, anxiety, and quality of sleep scores.

Rapid GP transformation

The loss of baseline funding and difficulty in recruiting GPs meant that Parchmore Medical Practice in Croydon was struggling to manage a rising workload. “We were using locums, which was costly and reduced continuity of care,” says GP partner Agnelo Fernandes. “Morale was low and we knew something had to be done.”

Deciding on revolutionary rather than incremental change, the practice implemented an ambitious package of initiatives. To manage same day capacity, a daily multidisciplinary urgent care clinic was opened, with a GP as senior decision maker supported by a nurse, a GP trainee, and paramedic.

Clinically inappropriate outpatient referrals have been reduced by holding daily GP referral peer review meetings. These meetings are followed by 10 minutes of physical exercise which has helped improve the general and mental wellbeing of staff.

The practice has employed two pharmacists and a nurse practitioner, which has helped reduce GP workload. The administrative burden has been reduced by training administrative staff to review letters and emails and only pass on those needing GP action. Another significant change has been the rapid rollout of social prescribing, with community hubs providing activities such as exercise classes and welfare support.

In just a year, outpatient referrals have reduced by 20% and emergency admissions by 18%. Prescription queries have reduced from an average of 30 to six per day per GP. “The practice is now thriving and we have much better morale,” says Fernandes.

Improving asthma care

A 2015 report into prescribing of respiratory drugs across the seven Welsh health boards showed that Aneurin Bevan University Health Board had the second highest cost per head of population and the greatest use of high dose inhaled corticosteroids. Subsequent practice audits showed evidence of reliever overuse, preventer underuse, and, in some cases, the absence of annual reviews, inhaler technique checks, and provision of action plans.

In 2017 the board appointed two lead primary care nurses to ensure correct diagnosis and appropriate treatment for patients with asthma and chronic obstructive pulmonary disease (COPD). They targeted the top 12 practices overusing high dose inhaled corticosteroids, providing clinical sessions and nurse mentorship.

The team has so far seen 1400 patients with asthma or COPD for a review. As a result, 500 patients had poor inhaler technique corrected and 100 had their diagnosis changed following an in-depth review and spirometry.

The team devised documentation to support the service, developing a spirometry protocol and a template to support nurses with clinical assessment.

Patients have given very positive feedback, says Natalie Janes-Plumley, lead respiratory nurse in the board’s primary care division. “They feel more confident about managing their condition, have improved inhaler technique, and understand the importance of taking their preventer inhaler.”

Janes-Plumley adds: “Close working partnerships have been key. We work closely with pharmacists to ensure that all healthcare professionals are supporting patient reviews and inhaler technique at every opportunity. We also work closely with public health to offer patients support with smoking cessation.”

DIY Health

Bromley by Bow Health serves one of the most deprived wards in London. It has a relatively high rate of new births and under-5s make up approximately 5% of the list size.

“We realised some parents kept bringing their children to the GP for minor ailments because they didn’t have the right knowledge or confidence,” says GP Khyati Bakhai. Some parents felt isolated and didn’t have family around them to offer support or advice.

Bakhai worked with Emma Cassells, the Patient First manager; parents; and other stakeholders to produce a peer-to-peer learning programme called DIY Health. The programme consists of 8 to 12 two hour sessions and is facilitated by a non-clinical team member. Topics covered have included management of fever, diarrhoea, skin conditions, and coughs and colds. Play specialists from the local children’s centre support the programme which caters for up to 12 parents per session.

Since September 2013 over 300 families have taken part in DIY Health. The scheme has trained several parents who can now facilitate the programme and has produced a free toolkit for others who want to develop such an initiative (https://uclpartners.com/diy-health-toolkit).

There has been a 35% reduction in attendance for minor ailments to GPs, emergency departments, out-of-hours clinics, and walk-in centres in the 12 months following the programme.

“Parents are more confident in managing minor ailments, says Bakhai. “They have also formed community connections and this has improved their wellbeing.”

Peer mentoring and coaching

Two GP appraisers were seeing high amounts of stress, burnout, and dissatisfaction in GPs in Nottinghamshire and Derbyshire. In 2014 they approached their local medical committees to see if something could be done.

The result was GP-S—a free peer mentoring and coaching service to support local GPs. The service has now expanded to cover Shropshire, Telford and Wrekin, and Sheffield, and will soon be launching in Staffordshire.

The most common reasons for contacting the service are career progression and general support, says Nikki Kendall, operational lead for the service. But it also helps with work-life balance, burnout, and stress.

The service has a team of 60 paid peer mentors—who may be retired GPs, locums, partners, or salaried doctors—who undergo an intensive two day training course in the mentoring model.

A secure online portal makes the system streamlined and efficient, says Kendall. Once a GP contacts the service, a mentor lead will make telephone contact within two working days to make an initial assessment. They are then matched up with a mentor who calls them within two weeks. Mentor and mentee then have up to four face-to-face two hour meetings at any time over a year.

So far, 280 doctors have accessed the service. Feedback found that 82% of doctors said they were going to stay in general practice as a result of using the service.

First contact physiotherapy

The Deepings Practice in South Lincolnshire is a semi-rural practice with 24 000 registered patients. The practice wanted to improve access for patients and considered ways to add value to patient pathways while redirecting patient flows. “In 2016-17 we carried out an audit which showed that 22% of face-to-face GP contacts were for musculoskeletal problems,” says GP Majid Akram.

The local clinical commissioning group agreed to fund a senior physiotherapist who would be integrated within the practice and see patients with acute musculoskeletal problems as the first point of contact. The physiotherapist was renamed a musculoskeletal practitioner and the reception staff were trained to direct appropriate patients to him.

The six month pilot scheme has been a resounding success. Around 42% of patients with musculoskeletal problems were shifted to the musculoskeletal practitioner; freeing up 350-400 GP appointments a month. Waiting times for musculoskeletal appointments reduced from 9 days to 3 days.

Because the musculoskeletal practitioner offered longer 20 minute appointments he had the time to promote self care more effectively. As a result, the musculoskeletal prescribing costs reduced by £9000 (€10 400; $11 800) over six months. There was a reduction in diagnostics such as x rays and outpatient appointments. “The musculoskeletal practitioner was investigating less, but more appropriately,” says Akram. The overall saving was £250 000 in the first six months.

Patient feedback has been very positive and the new pathway has not increased overall musculoskeletal demand. NHS England has championed the project and the practice is now part of a national pilot for introducing first contact physiotherapy within primary care.