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How a ‘focused care worker’ reduces GP workload and A&E admissions

The problem

We’ve all had that one patient who changes everything. For me, it was a young mum back in 2010 coming in with her eviction notice for unpaid rent arrears. ‘What can you do about this doctor?’ she’d asked. It was clear I would be unable to address her anxiety without dealing with her housing crisis but, frankly, was it even my business?

The current GP system is in obvious crisis and such problems often get bounced as ‘not health’. The other extreme is the many GPs who take on exhausting personal crusades on behalf of these patients. Instead, we started to consider what system could fix this problem.

I belong to a small team awarded one of the new APMS contracts. Starting in 2009 with no patients we now have six practices and 20,000 patients altogether. We needed to bring more healthcare into under-doctored areas. 

What we did

We decided a dedicated worker was needed to find ‘the problems behind the problems’. We hired a ‘Focused Care worker’, Ruth, to help these patients. A qualified nurse with experience championing poor families, she works four days a week, split across two practices. We now have four workers across eight local practices (four of ‘our’ practices and four local practices).

We designed a household assessment that the Focused Care worker carries out at every patient’s house, which comprehensively asks about the health and social issues not just of each patient but also every member of their household. Anyone can be referred (not only by our GPs and nurses, but by receptionists, housing officers and police), and Ruth and a GP will make a decision if that person would benefit and how well any previous care plan is working. Sometimes a quick fix will do, sometimes we stop at assessment as the patient actually has a working care plan. But most often this assessment highlights where the real focus of our efforts should be and which solutions we should be using.

We have regular discussions with the team about these previously invisible challenges, using the Gold Standards Framework (which is normally used to discuss end of life care) as a model for our discussions, except for our patients poverty and medical complexity (not cancer) were the villains. Our worker played the role of our Macmillan nurse bringing additional capacity and specialist knowledge yet encouraging the whole team to input their experiences and skills.

Ruth soon became an expert in local services and how to bend them to the benefit of our neediest patients. In the last year alone over 30 different local services from the public and voluntary sectors were accessed by our patients for the first time. For example, we used a domiciliary HIV service which was short on footfall. Ruth drove the patient to the clinic and stayed in touch with the patient until the HIV service took over visits and a care plan.

Our initial funding was achieved by tight housekeeping of our APMS contract (the fact that our social co-op does not pay any profit to shareholders or partners helped). 


We noticed that our patients needing focused care mostly shared two characteristics. The first was a lack of a clear diagnosis but a certainty amongst our experienced staff that significant problems existed – we used the term ‘failure to thrive’ for these patients. The second was a history of either being hard to engage with or a collapse of service provision due to ever tightening criteria (for example they were excluded from services by age or number of visits) or our patients’ own chaos. Sometimes being unable to make a phone call in a designated 10-minute slot is enough to derail a care plan. Being hard to engage and/or poorly compliant makes you more likely to be on the focused care list.

We were keen not to duplicate services but rather specialise in engagement, motivation and being downright stubborn with people (continuing to look after them until a solution is found). Most services reacted positively to this approach and began to behave differently to our patients. In our initial patient’s case the Housing Association became aware of her partners untreated mental health problems and worked with us admirably to support this young family rather than sanction them. 


As we began to unpick the complex problems of our patients we saw first our Public Health metrics soar (smears, immunisations etc) then we found our safeguarding processes visibly working better. Our audit showed 20+ households reduced their child protection status (ie went from child protection to ‘child -in-need’ or were discharged) whilst seven kids were taken into care as we proved a parent wouldn’t comply with any care plans. Ruth has capacity to attend most child protection meetings and supply reports.

The biggest shock was the discovery that this cohort’s use of A&E was evaporating (46% overall reduction) as they became re-engaged with routine primary care.

We also feel that us GPs have a significantly lighter workload as if we encounter a ’complex’ case we can delegate to a dedicated worker who does at least one home visit and can physically bring the patient with her to services if needed. Although busy we have high levels of job satisfaction in all our staff.

The future

These results allowed us to bid for innovation funds from NHS Oldham CCG’s ‘Dragon’s Den’ event and currently six of our neighbouring practices in Oldham help fund the service.

In Greater Manchester the Shared Health Foundation has approached us to help develop this ‘Focused Care‘ model and to gather together like-minded practitioners working in deprivation accelerating the learning from these teams and their communities. 

Dr John Patterson is a GP in Oldham