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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.