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Secondary care in a GP surgery

Nearly all secondary care for the 7,800 patients at the Gnosall surgery is set to be provided in-house at this state-of-the-art practice. Dr Ian Greaves explains how the model works

Nearly all secondary care for the 7,800 patients at the Gnosall surgery is set to be provided in-house at this state-of-the-art practice. Dr Ian Greaves explains how the model works

We have just submitted our integrated care organisation bid to become a patient-led social enterprise community interest company. We will provide most of our 7,800 patients' secondary care out of this GP health centre.

The social enterprise will manage budgets pooled from our practice, the acute foundation trust, the mental health trust, social services, the PCT and the on-site pharmacist.

41213201Our model allows not only the pooling of monies but also of primary and secondary databases and staff so we can better identify patients in need of managed care and have a greater workforce capacity to deal with such demand.

Our ICO bid will build on the long history of successful collaboration with the local hospitals and our experience with the PMS Plus contract. Our approach is based on the RCGP proposed route map for integrated care, which advocates federations of healthcare providers.

Importantly the identity and characteristics of each provider are still recognised and maintained but clear ground rules allow integration to happen.

In our model we have developed a workforce by seconding hospital and community staff but maintaining vertical responsibility with secondary care. Secondment has given staff peace of mind over pensions and other employment benefits and also meant their secondary care colleagues in the hospital have a sense of engagement and responsibility about services being provided, instead of feeling excluded or threatened.

The story so far

Gnosall is a rural district and its local economy is in recession. We have a large number of European migrant workers, deteriorating infrastructure and poor transport links.

The local population has increased over the past decade as a result of the creation of more elderly care housing and an influx of city commuters, resulting in more young isolated mothers living in the area.

Gnosall health centre is a purpose-built one-stop shop that has won design awards since it opened in 2006. It already offers integrated medical, pharmacy, dental, community nursing, physiotherapy, hearing and foot care services under a PMS Plus contract with South Staffordshire PCT.

Existing services include minor surgery, dermatology and near-patient testing.

Urology, musculoskeletal and dermatology services are already delivered by multidisciplinary teams including hospital consultants holding sessions at this practice. Our work on the early identification of patients with dementia through PBC has won awards.
The local hospital has already paid for and installed near-patient testing equipment for musculoskeletal and dermatology cases, including a camera and ultrasound machine, and they send their staff here to operate them once a week.

Since 1998 we have worked on creating an integrated nursing team with district nurses and health visitors seconded from the PCT provider arm (see left).

The social enterprise


We have applied for a £20,000 phase one social enterprise grant to get the company up and running. Our ICO bid has requested a further grant paid over two years to cover project, financial and data administrative staff, backfilling of locums for clinical staff, rental of rooms and a new integrated web-based computer data support.

Governance will be in the form of a council of governors consisting of staff, public and partner representatives who will provide the interface between a board of directors (to include a chair and three non-executive directors elected by the patient forum) and the membership and the local community.

The social services department is affiliated to the work of the social enterprise, but the way its budget is allocated means it was not possible for it to be part of the community interest company.


The shared financial model allows innovation in budget sharing, without risking trust finances or impairing patient choice as expenditure is ringfenced and based on historical spending in those areas.

Individual services from these providers will still be commissioned in the same way through service level agreements, so the commissioners will still decide the amount for each provider arm and in turn determine how much goes into the social enterprise pot.

The financial model allows budgets to be pooled in areas of mutual benefit but the core business of each partner will be commissioned in the usual way.

In addition, PBC will be used to allow the enterprise to provide case management for patients with long-term conditions so that their care is planned and managed by the multidisciplinary team.

To aid this, case management clinicians will have access not only to the QOF database but also to secondary care waiting list and outpatient data. This will ensure more patients who would benefit from a health and social maintenance input can be identified.

Patients themselves have raised £50,000 through car boot sales and other activities. This will be kept as a financial reserve, although it is unlikely that it will ever have to be used. The patients' contribution proves they are much more than token partners in this project.

Service level agreements will define the vertical and horizontal governance arrangements, with senior clinical leaders identified for each area of care and to ensure patient safety.

The ICO bid

• Expanding the work we have done with dementia patients (see box bottom) to include social care.
• Doing most outpatient and treatment therapies for all specialties on site, through the creation of a new hospital doctor role.
• Managing patients with stable ophthalmic conditions by a named optometrist at a local location.
• Introducing a new urgent care model for patients to access either at the GP surgery or at satellite centres out of hours. This would be provided by junior doctors from secondary care, who would work closely with other stakeholders including the ambulance trust and NHS Direct.
• Adding acute trust nurses to the integrated nursing pool, so more patients can be cared for in their own homes
• Managing patients identified through the pooled databases using a model akin to the community matron, but with the clinical lead GP supported by a multidisciplinary team.
• Seconding a social worker to create a non-means-tested urgent care team to maintain people at home and facilitate planned early discharge.
• Introducing integrated mental health packages so patients can be screened and treated earlier.

We anticipate that redeploying resources will enable us to:

• reduce hospital admissions by increasing the menu of community care at home services
• increase services for the elderly
• initiate a pre-admission discharge plan for elective cases involving vulnerable patient groups such as the elderly
• create discharge plans for vulnerable patients for non-elective cases.

Central to these proposals is expanding the workforce. Our integrated nursing team has been crucial and in the future we propose to create a new doctor role.

The integrated nursing team

Back in 1998 we seconded district nurses and health visitors from the PCT provider arm under our PMS Plus contract. This meant that practice and community nurses could both do home visits and see patients in the practice. An analysis of reference costs for our nurses showed they were a third of the national figure.

Our current team comprises:

• three district nurses – 22 half-hours each
• two healthcare support workers – one providing 22 half-hours and the other 30 hours
• four practice nurses – 20 hours each
• one mental healthcare worker – 30 hours.

This nursing team has allowed us to pilot planned hospital admissions with the help of a practice-attached social worker, and we intend to reintroduce pre-admission discharge plans that will involve care packages of medical, nursing and social care for individual patients (see hip replacement box left).

Linking the hospital and PCT databases will mean a case care co-ordinator will be able to identify patients in the care pathway system. This will allow direct case management and promote the health maintenance model of care integration. The nursing team has also been able to take on care closer to home, to prevent hospital admissions and allow early discharge.

The plan for the future is for Mid Staffordshire Acute NHS Foundation Trust to create a bank of nurses – a virtual ward – that will be deployed to the areas of the ‘hospital' that have the greatest need.

The ICO will have access to these nurses, who will supplement the community nursing team to care for people in their own homes and enact the PCT's ambulatory care plans. This will ensure greater flexibility to react to demand.

The practice owns a residential home nearby and this is being extended to provide up to seven purpose-built extra beds for respite and intermediate care.

Seconding hospital doctors

We now plan to offer a large number of outpatient appointments in the health centre and expand our urgent care services by creating a new hospital doctor role.

This will be a 15-month contract for a doctor who has done their SHO 1,2,3 training but not done a specialist training post. It will be a trust-grade doctor post and the first three months will be spent attending only outpatient clinics at the hospital alongside the consultants.

This allows the consultants to get to know the doctor and establish a trusting and personal relationship between them. The outreach doctor will learn how the hospital consultants apply national guidelines and will get experience of all the specialties.

After their three-month training the outreach doctor will be based at the surgery. Patients requiring a hospital referral can be seen by the outreach doctor the same day or the following day at the practice. The outreach doctor can do the necessary tests and work up the patient before presenting the case to the hospital consultant.

There is vertical accountability with the hospital consultants, who do not feel disenfranchised as they retain relationships with the doctor. This is different from triage, as the doctor is taking responsibility for the patient as they would in a hospital.

The consultants' notes are directly recorded in the practice computer, so there is no need for hospital letters. Prescriptions are also issued from our computer.

The outreach doctor will also be able to help GPs and nurses at the practice with the management of comorbidities. The outreach doctor post will be paid for by PBC savings and will cost £38,000 a year for a 48-hour week. We have been inundated with applications. Candidates are keen because of the increased portfolio the post offers.

Urgent care

We will also use seconded hospital doctors in our new urgent care service. A doctor, either a senior GP or A&E consultant, will supervise the doctor providing the urgent care service at our practice by telephone. If a situation arises where this is clearly not appropriate, the patient will be directed to the emergency services.

Urgent care appointments will be offered at the practice from 6.30pm to 10.30pm every weekday evening and from 9am to midnight at weekends and bank holidays. The doctor will also handle telephone consultations and triage, and make home visits if appropriate.

The Choose and Book Room

The practice is committed to maximising patient choice and so we have created a Choose and Book room. This contains files with details of other providers that patients can browse, plus a computer for patients to access information online.

We envisage that we will be able to offer choices at different stages of the patient journey. So at the outset the patient will be offered the choice of being referred in the usual way to hospital or going through the in-house managed healthcare system.

We also have patient leaflets explaining how our model of care differs from the traditional pathway. And, of course, that is still available as an option if patients want that.

Dr Ian Greaves is a GP in Gnosall, Staffordshire, and a fellow of the RCGP. He sits on the NAPC members forum

60-second summary A different patient journey An integrated mental health care service for dementia

Under PBC we have set up a service with the primary aim of identifying, investigating, treating and supporting patients with dementia.

Primary care is often criticised for failing to pick up patients showing early signs of dementia, primarily memory impairment, and for failing to organise appropriate assessment and mobilisation of education, treatment and support for individuals and their families.

A consultant old-age psychiatrist holds a monthly clinic at the practice to make early assessments of dementia and provide ongoing treatment. He is supported by
a health visitor who has a key role in gathering and co-ordinating information and liaising with patients, their carers and other professionals.

Referrals to the clinic arise from screening our vascular risk registers or when problems are identified through clinical contact.

We plan to trawl the practice registers for diabetes, CHD, hypertension and AF. If necessary the consultant and health visitor will go to see the patient at their home or care home.

In the first year, 20 patients were referred after the GP or health visitors did the clock test or Brief Assessment Schedule for Depression Cards (BASDEC).

All but one have been found to have some form of organic brain disease, with 10 being diagnosed with vascular dementia and seven Alzheimer's disease. Brain scans have been requested for just two patients at the hospital, and only one has been referred to the hospital consultant clinical psychologist.

Only one patient has been admitted to a care of the elderly ward. Fifteen of the 18 patients originally living at home are still there, two have died and one has moved into care.
Dementia diagnosis time has been reduced from three years to four weeks.

Dr Ian Greaves: almost all secondary work in his area is done at his surgery Dr Ian Greaves: almost all secondary work in his area is done at his surgery

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