Brownlow Health is a large inner city GP practice in Liverpool. We have a population of over 27,000 patients- just over half of these are students.
We also have over 700 patients who are registered as homeless and 600 who are drug users. This group with complex needs live mainly in hostel accommodation.
The rest of the population includes established city dwellers as well as young professionals who live in recently developed city centre apartments.
The team that has grown up to meet the needs of the patient includes nurse practitioners and specialist nurses working alongside a GP and practice nurse team.
The team operates from four sites, three in the city centre and one at the one at a halls of residence, and two of the sites (one on campus and the one in halls) are nurse-led.
The partnership has developed over the years to become multi-professional and consists of eight partners – six GPs, a business partner and a nurse partner.
Established as a student health service in 1994/5, the practice began developing services for the homeless and drug users the following year and has grown since then to its present list size of 27,000 patients. It was recognised early in the development of the organisation that traditional approaches to general practice would not necessarily meet the needs of the population.
What we did
From the start we have identified the needs of our various patient groups and have grown the team by recruiting staff with the right skills. This turns out to be a team that now comprises eight partners, 12.75 full-time equivalent GPs and up to four GP registrars at any one time, as well as a psychology service – a clinical psychologist plus three trainees.
The practices also have a nursing team of 15 staff – some part-time, some working during the university term only – headed by a nurse partner that included an operational manager, first contact nurses, practices nurses, health care support workers and a specialist team engaged in a range of services for the homeless/vulnerable adults.
We have a comprehensive administrative team led by a practice manager who works closely with senior management and the clinical team to deliver appropriate services to our population.
This clinical team offers a walk-in service for all patients, specialist services including: student health, homeless outreach, a Hepatitis C specialist nurse identifying and treating patients in the community and an alcohol nurse specialist. The practice work closely with other agencies and have services such as drug support workers, a health trainer and alcohol services working in one of the sites.
How we did it
Developing core values, creating a non-hierarchical team structure and a patient centred vision early on ensured the team we recruited were non-judgemental and felt able to influence decisions regarding the provision and development of services.
The practice was initially established as a student practice. It has grown by growing the regular list, by successfully winning contracts through local tenders, LES provision and by responding to health needs identified by commissioners, localities and neighbourhood.
Early on the development of the practice, we recognised that students often presented with health problems that are often best managed by nurses. In fact one of the sites that offered services was a sick bay at one of the Halls of Residence which was nurse run.
Health concerns presented by students included:
- self-limiting minor illness
- sexual health screening
- requests for contraception
- travel health.
Also issues such as loneliness, home sickness, and exam anxiety are common. Practice nurses working with the Practice were trained in sexual health, family planning, and clinical examination skill and prescribing. Over the years the nurses have increasingly led the clinical care of students for management of minor illness, and general health maintenance activities. The nurses are supported by GPs who deal with complex health problems, mental health problems. For students away from home for the first time (many from overseas) a less medicalised approach to care delivery is appropriate.
The other group of patients that benefit from specialised nursing are the homeless, substance misusers. The practice is commissioned under a LES to provide a homeless enhanced service. Over and above that, we undertake outreach in the cities homeless hostels providing health advice, health promotion, immunisation, screening as well as a weekly GP led clinic for any of the city’s homeless population.
Further services have been developed to work alongside the core two-nurse team providing outreach. One of these, a community nurse service offering screening, assessment and treatment of patients with Hepatitis C, won a national award. The most recent service – focussed around patients with frequent A&E attendances related to alcohol misuse – is showing huge gains in addressing the health needs of problem drinkers and appears to be successful from a cost-saving perspective in avoiding admissions to secondary care and accident and emergency department (AED) attendance in hours.
Through working at a neighbourhood level (with two other local practices), we have also established a wound care service for the homeless population in collaboration with The Basement – a local homeless charity.
In another recent initiative, a proactive approach to the management of vulnerable adults (mostly people with alcohol and/ or drug use problems) is being piloted. Using recent AED data, patients are reviewed on a two-weekly basis by a multi-professional team that pulls in key clinical staff from primary and secondary care as well as Local Authority and third sector staff to identify heavy users of services and develop proactive care plans and appropriate pathways.
Our business partner is a key player in terms of developing business cases, spotting development opportunities and winning contracts. She also steers services and provides support and encouragement to achieve goals and targets. Our nurse partner engages with the nursing team and enables them to develop services and share the vision of the organisation.
A multi-professional approach has delivered a comprehensive team that delivers care for diverse groups of patients in a challenging city centre environment.
Over recent years this has enabled a number of innovative initiatives that have delivered improvements:
- There has been a reduction in AED attendances following the introduction of a walk-in service.
- The wound care service at The Basement has resulted in improved healing rates and reduction in admissions for cellulitis.
- Increasing numbers of young women are now using Long Acting Reversible Contraception (LARC) – a change that is supported by commissioners
- Collaborative working is beginning to see the development of primary/secondary individualised pathways for patients who are heavy and expensive service users
The practice will continue to explore innovative approaches to dealing with clinical issues and problems. A next step is to see if initiatives can be replicated elsewhere and deliver similar results.
Clinical commissioners are charged with delivering the QIPP agenda. Multi-professional approaches are a key part of delivering quality care at a time of increasing demand and dwindling resources
Dr Ed Gaynor is a GP and Tina Atkins is the business manager at Brownlow Practice.