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At the heart of general practice since 1960

GP-led scheme reduced emergency admissions by 'more than a third'

An integrated care ‘pioneer’ scheme involving three GP practices in Cornwall, and led locally by one of the GP partners, has reduced emergency admissions in a group of high-risk patients by 34%.

Since January 2014, GPs in the Penwith area have been able to refer patients to the Living Well scheme, under which vulnerable people with two long-term conditions relying heavily on health and social care can get regular additional support from a community team spanning health, social care, voluntary services and the police.

Headed up locally by Penzance GP Dr Matthew Boulter, the project is funded via the Better Care Fund and with support from elderly charity Age UK.

NHS Kernow CCG said the patients identified via the scheme were often people who have become highly dependent on formal care in combination with suffering from social isolation, with the community support team (which includes GPs) helping them to build confidence to take small steps towards improving both their health and social inclusion.

The CCG’s evaluation figures are based on a cohort of 325 people who were supported by Living Well in Penwith from January 2014 to January 2015, finding over the period:

  • a 34% reduction in emergency hospital admissions;
  • a 21% reduction in emergency department attendances;
  • a 32% reduction in hospital admissions overall.

Patients qualifying for the scheme suffered conditions including diabetes, COPD, heart failure, memory loss, dementia, Parkinson’s, hypertension, stroke, osteoporosis, repeat infections or had a high risk of falls, had relied on early interventions or emergency care callouts three times or more the part 12 months and/or received social support such as lunchtime visits.

Speaking about the scheme, Dr Boulter said it was ‘revolutionary’ for patients and ‘hugely satisfying’ as a GP.

The news comes as the number of emergency admissions to hospital on the whole increased across England in 2014/15 despite interventions such as the Avoiding unplanned admissions DES being rolled out in GP practices.

Penwith is one area within the Cornwall and Isles of Scilly integrated care pioneer schemes, one of 14 announced by the Coalition Government in November 2013.

Readers' comments (9)

  • This is no more than every GP has been saying for years. If you withdraw social care the social needs dont go away and end up as perceived medical needs. Joined up thinking may helps sometimes

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  • Reversion to mean or was there a control group? Nuffield trust did some work a few years ago pointing out the poor methodology of these 'studies'.

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  • This is actually pretty poor figures tbh, I would have expected a greater percentage reduction,
    i hope GPs and patients benefited though and perhaps patient quality of life improved

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  • once the money dries up, it will stop and everyone will have to provide the service for free. Why bother?

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  • Not rocket science. Unfortunately accepting emergency admissions due to a failing system appears more cost effective for the government than providing funding that would provide good overall care.

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  • Probably costs more in staff payments than it saves in hospital admissions.

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  • As noted above without a proper control group reports like these are no more than a good story.
    A marked regression to the mean was seen in the dodged up reports put forwards to support community matrons.
    Which is sad because I think that they do work, are probably cost effective and should be expanded.
    But sometimes these community schemes like this don't work and it is probably detail of what the intervention actually is, who does it and to which risk group.
    Community pharmacist reviewing patients on hospital discharge in one RCT increased readmission rate.

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  • No money, no funny. Will the funding continue? Don't think so. As already been mentioned, why bother?

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  • The above comments, healthy cynicism and interest in this story are welcomed - thank you.

    The results presented here are for the first cohort of 325 people with over 1200 recruited to date. Further tranches of data will be released approx every 3 months. Many, many more people have been helped and supported by Living Well but not all meet the entry criteria. Entry to the study is blinded to clinicians and other staff.

    We do use "proper" matched controls and have a professional team including academics from Exeter University who remotely access IT systems to monitor outcomes, activity and spending. Whilst all studies are open to criticism, we are doing our best to be as rigorous as possible.

    Initial funding for the Penwith area (we have now rolled out to elsewhere in Cornwall too) was from a legacy. However, the return on investment is almost 3-4 to 1 so our CCG are now supporting this as they can see the cost benefits. The challenge is to free up the money saved in the acute sector for redirection back to localities to fund Living Well long term.

    As one of my colleagues has pointed out, even if Living Well doesn't save a single penny, we are delivering a vastly improved service and we are creating a lovely system to grow old in.

    One angle that this story did not highlight is that 1 in 5 of the people that Living Well supports, end up becoming volunteers themselves - even though many of these had been "written off" by health and social care. Many had been declared "housebound".

    At a personal level, I have wandered in to this by happy accident and am (proudly?) not a medical politician and have no senior role within our CCG. This is a local, clinician led, bottom up initiative which is showing what seems to be really quite impressive results. Having a voluntary sector worked permanently embedded in each local GP practice is now business as usual for us and we see the benefits daily.

    We are happy to openly share what we doing and have created www.knowledgebucket.org to assist with this.

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