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Using a community matron to cut admission rates

Health and social services staff successfully collaborated to target patients at high risk of hospital admission in a pilot scheme that has been rolled out – Dr Alex Williams explains how

Health and social services staff successfully collaborated to target patients at high risk of hospital admission in a pilot scheme that has been rolled out – Dr Alex Williams explains how

Our practice piloted a long-term conditions (LTC) project in 2004 that, thanks to its success, has been rolled out across Exeter.

The premise of the pilot was that we should be able to identify a group of patients at high risk of hospital admission and offer them an enhanced community service.

This would involve a community matron assessing the patient's health and social care needs, and then liaising with the patient's GP, district nursing team and social services – particularly occupational therapy – to maximise help and support. She would also delegate tasks to a healthcare assistant, who would carry out basic nursing and social monitoring at the patient's home.

41181042A domiciliary pharmacist would review medication, check on compliance and ensure changes following any hospital admission were enacted.

We were approached by the then Exeter PCT asking if we would like to get involved, as our large practice of 13 partners, together with a smaller single-partner practice that would work with us, had a patient population of 30,000. This is similar in size to the Kaiser Permanente model of managing complex health needs used in the US and now exported to the UK.

The pilot size was also the anticipated size of other clusters across Exeter that would adopt the model should the pilot be successful.

Among our partners there is a healthy degree of scepticism of anything new, but we had become involved in PMS when it was first launched in our PCT and we had seen the advantage of getting involved in new projects at inception, when most of the financial inducements and benefits are available.

We were told there was no financial risk to the practice with commissioning: any overspends would be met by the PCT, and any savings would be split 50:50 between the PCT and practice, so it seemed too good an opportunity to miss.

My analogy for commissioning is that it is like an onion. You take some time peeling away the layers to expose the fleshier parts of the root that you can get to grips with.

Considerable groundwork

The pilot was launched in March 2004, after considerable groundwork by a project manager – a senior nurse seconded from the local NHS trust – and a core team of health and social care staff. The new posts were advertised and appointed in a tight timeframe, and funded by the PCT.

The core team met weekly to identify problems and solutions, and drive the implementation forward.

Meetings sometimes suffered from inertia and a need to cover old ground. We also found that, as other agencies were consulted, we were flooded with new ideas and perspectives. It seemed a case of one step forward and two back.

However, some very useful relationships were being formed and the barriers between health and social care were being broken down.

There were some start-up costs as we required some office space and equipment for the matron's base. Fortunately we had just reclaimed some office space above the pharmacy based within our health centre.

We held a useful team half-day as a bonding session and performed some patient mapping exercises to identify areas that might be useful at preventing admissions in the future.

Not only was this very interesting and informative but provided some possible alternatives to admission, such as access to community-run nursing home beds and easier access to both respite and rehabilitation.

How we identified the caseload

Deciding which patients to target was quite complicated and has evolved over time.

First, we had a list from the hospital of anyone admitted more than twice in the past two years – which gave us quite a lot of people. I was keen very early on to stress that these might not necessarily be the people we most needed to be seeing, and that we should look at people becoming ill in the next six months or a year, such as a newly declared patient to us, who might typically be an elderly, frail woman on polypharmacy and living alone.

Then the matron and pharmacist met with the relevant GP partners to discuss the patients to refine the list. The OT manager also gave us useful information about some of the people we knew and some we didn't know who could benefit from our intervention. The list came down from 100 to a more manageable 40 to 50.

Patient management

All patients have a contact assessment from one of the LTC team and then hold their own record, which contains their personal and social information, details of any medical conditions or medication, and a log of all visits. At times of hospital admission the record can accompany the patient along with a computer-generated summary of their medical record.

Health and social care team members – the matron, pharmacist, social services and the co-ordinator of Friends, the voluntary sector group supporting the health centre, plus others as needed – meet on a weekly basis to discuss patients' needs.

Patients are coded on a traffic-light system as green (new clients), red (active clients with intensive input) or amber (clients discussed from the long-term conditions list).

A useful template is updated, outlining patient needs and interventions offered, and is then emailed after each meeting to all GPs so they can see what has been provided for their own patients. Patients move on as they are newly declared and referred, then move off by becoming stabilised, moved into nursing or residential home, or if they die.

The matron acts as the central axis in co-ordinating all the referrals and the day-to-day management of the caseload.

It is extremely useful that she has office space in our building and access to our electronic records in order to access details about the patient, their conditions and medications.

Any interventions can also be recorded in the journal screen, so they are clear to other team members.

It is useful to be able to wander down the corridor and initiate a referral by face-to-face contact, rather than by paper to somebody you don't know.

We are blessed with a very dedicated and caring person in the HCA role, who is always willing to go the extra mile in patient care. She undertakes any tasks the matron asks, including dressings and personal care.

She also provides valuable emotional support to patients and their carers, who often use her as the access point to the health centre.

The community pharmacist's role is to try to help patients with their medication and compliance. He performs assessments at home (sometimes with the matron), using medicine boxes, blister packs and printed laminated sheets with simple instructions.

He will check on any changes in medication following admission and facilitate the reordering of medicines, for the elderly and frail, co-ordinating with other agencies such as the pharmacy and the ‘friends' group that help with delivery. For two days of the week he is also our PCT pharmacist and helps with our prescribing incentive scheme and targets, so sometimes his roles overlap.

If changes in medication are suggested, he either emails a message on our intranet or sends a written message, then checks after an interval that this has been actioned.


There were 35 (3.3%) fewer admissions during the nine-month pilot, compared with the preceding year and set against an increase of admissions in other clusters of around 10%. This resulted in a £339,000 saving on our commissioning spend for the year. Overall GP contact by this patient group also fell by 29% – most significantly for consultations (62%).

We also used the Nottingham Health Profile, a validated questionnaire, to show that quality of life among patients improved overall by 16%, particularly through a reduction in social isolation felt by patients (33%) and improvements to their emotional wellbeing (31%).

As a result of the pilot's success, the team was kept on and the model rolled out to three other clusters in Exeter.

Since the pilot, we have not specifically monitored admissions in this group, focusing more on monitoring activity for our total budget.

We continue to underspend, despite some budget reductions, and are now having to make bids from the total monies saved by all GPs across Devon – following the merger of Exeter PCT with five other PCTs into Devon PCT – to commission new services and continue funding those we have already developed. This is proving a major headache and a considerable disincentive to us to continue with commissioning.


When the pilot started and before everyone was settled into their new roles, partners may have been a bit sceptical. But we quite quickly saw the project's potential.

I think one of the strengths of our pilot was that it involved one large health centre and a much smaller single-partner practice that allowed centralisation of resources, and easy access to the clinicians involved in day-to-day management.

Another strength of our approach was the integration of health and social care.

The community matron was pivotal to the successful running of the pilot and the transition into a rolled-out service. She and her team have been a great success and are now fully integrated into our team structure and complement the services we can offer.

Dr Alex Williams is a full-time GP, lead trainer, and managing partner of a large practice in Exeter

Dr Alex Williams 60 second summary

Overall GP contact by this patient group fell by 29%

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