‘People should be given the medicines they need, when they need them, and in a safe way.’
CQC Essential Standards, Outcome 9 – Management of medicines.
Our recent experience includes designing in-practice and in-community pharmacy services for the Heartbeat Alliance, a federation of 21 practices in North Yorkshire. We worked with recruitment and locum supply agency Medacy to provide staff, assess impact and deliver data to the Board, minimising workload for the practices while measurably improving patient care.
‘Pharmacies will help manage minor ailments and common conditions, by the provision of advice and where appropriate, the sale of medicines, including dealing with referrals from NHS Direct/NHS 111. Records will be kept where the pharmacist considers it relevant to the care of the patient.’
(Source: PSNC essential service 6)
We have led the design and implementation of a community pharmacy-based minor ailments service that provides advice and support, including the supply of medicines to people who would have otherwise gone to their GP for a prescription.
- More choice of access to healthcare advice and support for patients.
- Reduces pressure on primary care and general practice in particular.
- Reduces unnecessary A&E attendances.
Physiotherapy in general practice
‘Greater use of the physiotherapy workforce within primary care is a cost -effective and clinically-effective way to reduce the pressure on GPs and deliver the whole-person care required of a modern primary care sector.’
(Source: Chartered Society of Physiotherapy)
We have co-ordinated and programme managed a pilot project to bring physiotherapy into general practice, facilitating easy and rapid access to specialist support for patients. Physiotherapists with appropriate MSK training, experience and qualifications provide a direct access service to assess, diagnose and triage for MSK problems.
- Reduced pressure on GPs by offering patients direct access to physiotherapists working in their practice and able to offer assessment, initial treatment and advice.
- Reduced number of inappropriate referrals to secondary care.
Frailty and care homes
‘Older people living with frailty are at risk of dramatic deterioration in their physical and mental wellbeing after an apparently small event that challenges their health.’
(Source: British Geriatrics Society)
We have led the development of a frailty pathway that uses the electronic frailty index to identify and stratify patients diagnosed with frailty using the concept of cumulative health deficits.
The pathway runs through the different elements of an integrated model of care, that includes care homes, and has multiple benefits both to patients (in terms of outcomes and better quality of life) and to the health economy by reducing the crises that result in the need for patients to access primary and secondary care, both urgently and routinely.
The project integrates care homes
An estimated 380,000 people live in approximately 17,000 nursing or residential homes in England – 95 per cent of them over 65. Care home residents have complex needs and these health care needs are not consistently well-met. ‘Enhanced care in care homes’, is one of the new care models set out in the NHS Five Year Forward View, intended to offer older people better, more joined-up care and rehabilitation services.
- Gives insight in to how telemedicine can support patients and carers in a small cohort of homes and inform plans for future use of this type of technology.
- Provides access to clinical records and where necessary, in selected care homes, develops wi-fi networks that will allow practice and community access connectivity when attending patients in care homes.
‘Giving patients 24/7 access to online resources and the ability to e-consult their GP means they are able to gain advice sooner than usually available through a GP appointment. By accessing care sooner, we can infer that they were likely to get better health outcomes.’
We have led a pilot e-consultations project in various settings, exploring their use outside of normal GP opening times. This has included equipping clinicians and other practice staff with the skill sets to make the most effective use of e-consultations.
- Bridges the gap between GP opening hours and times when patients find it convenient to access their GP.
- Reduces pressure on GP appointments.
- Reduces inappropriate A&E attendance.
- Improves the quality of experience for patients due to the greater choice offered for access to health advice and support.
Out of hours
‘General practice has a vital role to play in the delivery of effective patient care at all times of day, including outside normal working hours. Those seeking help from the NHS at this time are often at their most vulnerable, and for many of these patients general practice is best placed to provide the care they need.’
Extending the range of work carried out by out of hours doctors is crucial to improving patients’ experience of using and accessing urgent care services, making sure they receive the best care, from the best person, in the right place, at the right time.
Our work makes use of all possible capacity of out of hours, supported by technology, to reduce the number of out of hours cases redirected to A&E.
- Allows clinicians to see patients’ GP records regardless of which clinical system is used by their home practice;
- Enables better informed and safer clinical decision-making than is otherwise the case in urgent care settings;
- Has the potential to use the out of hours doctor to triage calls from NHS 111 (subject to revision of the NHS 111 algorithm, to ensure that GP triage occurs at the most effective point in the process).
‘Engage with patients, carers and the public when redesigning or reconfiguring healthcare services, demonstrating how this has informed decisions.’
(Source: Health and Social Care Act 2012)
Led by us and delivered in association with our partners, our project increased communications and engagement with members of the public, patients and clinicians across all organisations, facilitating the development of services and discreet projects that respond to local need and achieve the intended outcomes.
We used all available platforms, digital and real world, to reach every household in the Hambleton, Richmondshire and Whitby CCG territory. The campaign stretched across schools, businesses and leisure outlets, ensuring that everyone could easily access an opportunity to respond to and comment upon future plans.
Patients living in remote and rural areas can face problems accessing appropriate healthcare because of poor public transport infrastructure. These problems can be particularly acute for frail and elderly patients, and young people.
Our work delivers:
- Easier and more convenient access for patients to primary care
- Faster discharge rate from hospital
- Reduced inequalities faced by patients
We have led a project that included these elements:
- Transport to primary care facilities (where currently contracts focus only on transport to secondary care).
- Full review of transport arrangements for those attending secondary care facilities.
- A small scale pilot of the “Health Cab” concept – a tailored taxi service targeted at patients undergoing dialysis, chemotherapy and radiotherapy.
- Providing home from hospital transport that would significantly improve the speed of discharge from hospital. This would be coupled with establishing close links between practice based clinical pharmacists and their hospital based colleagues and a medications delivery service, which would ensure:
- An option can be given for medications to be delivered to the patient’s home from their local pharmacist or dispensing practices on the day of their discharge.
- Patients are not kept waiting for hospital pharmacies to dispense their medication
‘We know from people in our care that they value and trust nurses. We know that this confidence in nursing is founded on the enduring values and behaviours which demonstrate excellence in nursing.’
(Source: Department of Health)
As care is increasingly delivered out of hospital, in communities and people’s homes and will involve long-term relationships to support people to manage long-term conditions and co-morbidities. Nurses will be key professionals in planning and providing this care. Maximising the efficiency of the primary care workforce through better enabling practices to work together, with the integration of nurse resources a key part of that strategy.
- Allows seamless care between different parts of primary care and better overall care, minimising the number of crisis points where avoidable admissions to hospital can occur, as well as pressure on GP in and out of hours care.
- Delivers a more equitable and effective distribution of specialist skills and knowledge.
- Breaks down the distinction between housebound and ambulant patients.
Clinical pharmacy in general practice
- Post-discharge medication.
- Polypharmacy and multiple co-morbidities.
- High-risk medications and related crises.
Our programme delivers these outcomes:
- Reduces the medication review and related work that GPs currently undertake.
- Reduces the number of occasions where a patient needs a GP appointment, thereby increasing capacity at practice level.
- Facilitates a quicker hospital discharge process.
- Provides a better quality of long-term conditions management.
- Reduces the occasions of medicines-related crisis that result in attendance at A&E and/or hospital admission.
Effective care coordination for patients with multiple conditions and other complex needs
NHS community matron services are currently focused on the most challenging top 0.5% of the needs profile. But there is significant opportunity to improve self-care and treatment adherence for the next most needy groups.
Holistic, pro-active and person-centred, our approach has been tested over 15 years and uses international best practice to improve patient experience and quality while delivering savings through reducing patient need for and use of high-cost services.