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Please click here to view Principia MCP's 2017/18 Programme Evaluation Report.


GP participation in an MCP - My Patients, Dr Neil Fraser

Dr Neil Fraser, a GP from East Leake and Lead for Long Term Conditions with Principa Partners in Health multispecialty community provider (MCP) vanguard, talks about the changes they have made to how patients access care and the effect this has had. He talks specifically about mental health services, long term condition (LTC) management and care homes.


PartnersHealth Development – Collaboration in General Practice

PartnersHealth was established in 2015 and sees all 12 GP practices across Rushcliffe working more closely together through this local partnership of general practice. PartnersHealth is the cornerstone of Principia and has been the driving force behind much of its success in establishing new community outpatient and triage services in the community rather than hospital settings. Local GPs, through PartnersHealth, have worked closely with CCG commissioning managers and the service improvement team to re-design the journey patients take through the NHS system for some clinical specialities to improve quality and access to care.

During the last year, PartnersHealth has seen increasing collaboration to improve consistency in standards of care and patient access across all 12 Rushcliffe practices and reduce variation in referrals to secondary care. PartnersHealth also aims to ensure the sustainability of general practice through reducing duplication and has identified areas where collaborative working can improve efficiency and streamline processes and information sharing.

PartnersHealth also welcomed a new lay chair in June 2016, Kamaljeet Pentreath, who has been an influential patient leader on the CCG’s Patient Active Group and the Radcliffe Surgery Forum.


GP Enhanced Specification – Standardising Care and Long-Term Conditions Management

This specification for GP and primary care services in its second year goes beyond the standard offer to include improved data management and new metrics to better assess quality of care.

The specification supports standardising patient care based on best practice and clinical evidence, including opening hours and access to appointments. The development and roll-out of standardised referral processes and training across Rushcliffe GP practices has seen a reduction in the clinical variation for elective first outpatient referrals – equating to more than 1,000 fewer secondary care referrals over the last year.

All 12 PartnersHealth member practices signed up to the 2016/17 enhanced offer which included an improved home visiting model, risk profiling for heart failure and chronic obstructive pulmonary disease (COPD) and improved identification of patients at risk of diabetes. This year’s contract also included a greater focus on improving the quality of end of life care for patients choosing to remain at home.


Seven Day Services – New Weekend and Evening Appointments

The CCG applied to become one of 18 transformational areas in the country to accelerate increased access to GP services and in 2016/17 was successful in securing additional national funding to support the provision of additional primary care appointments. Patients in Rushcliffe now benefit from additional appointments in the evening and at weekends as part of a new seven day primary care service.

PartnersHealth has worked with its GP members to provide the staffing and premises needed to expand the service offered to patients outside core hours. Patients registered with any Rushcliffe practices can book appointments up to 8pm in the evening on weekdays and on Saturday and Sunday mornings, available from three different locations in Rushcliffe. With explicit patient consent, medical history and patient information can also be viewed by any Rushcliffe GP to ensure care is consistent and based on the right information, whether during core hours, evenings or weekends.

Click here for a leaflet about our extended hours service 


Improving Care – Choice and Dignity at End of Life

PartnersHealth has supported its practices to implement a standard approach to care for all patients approaching the end of life. Practices now use a nationally recognised, evidence-based approach to optimising care for these patients. Individual end of life care planning is based on a patient’s prognosis and preferences and ensures co-ordination and collaboration within and between healthcare teams to reduce crises and admissions to hospital. This enables appropriate pain management and allows more people to have their choices respected in the final weeks and days of life.

This is facilitated through the use of the electronic palliative care coordination record system (EPaCCS) used by GP practices – a whole-system approach that co-ordinates the sharing of vital information to all key healthcare providers. Through proactive work with GP practices and community health teams, Rushcliffe has achieved the highest number of patients registered on EPaCCS in the whole of Nottinghamshire. In 2016/17, more than 73% of local patients were supported by health and care professionals to be able to die in their usual place of residence or preferred place of care. Rushcliffe also has the highest number of patients in the County who have been engaged in their end of life care planning and had their resuscitation wishes recorded.


Community Services

Gastroenterology Clinic – Diagnostics in the Community

A Gastroenterology Pre-Assessment Service was launched in October 2016 and sees a gastroenterologist working within primary care to triage patients (excluding those with suspected cancer). Based at the Castle Healthcare Practice in West Bridgford, the community clinic assesses patients to see if they can be managed by their GP, need further tests or should be referred for a hospital appointment.

Since the launch of the Gastroenterology Pre-Assessment Service to the end of March 2017 there have been 148 completed referrals onto the pathway. Of these, 42 referrals (28.3%) have been returned to the GP with advice, avoiding the need for a secondary care appointment. Pilot data suggests the service will reduce routine gastroenterology appointments in secondary care by up to 23%.

The service has since been expanded to include the option of the gastroenterologist ordering and interpreting diagnostics from within the community setting and has also been rolled out to two neighbouring CCGs. This new model of care will be used by Principia for additional clinical specialties to bring care closer to home and avoid patients needing to attend outpatient clinics at the hospital.


Community Gynaecology Service – Care Closer to Home

The Community Gynaecology Service, based at Keyworth Medical Practice, launched in May 2016. Local GPs work alongside a consultant gynaecologist to provide advice, follow-up and treatment for conditions such as cervical polyps, severe premenstrual syndrome, menstrual and menopause-related disorders, pelvic pain and polycystic ovarian syndrome.

Patient feedback from those using the service has been incredibly positive, with many women choosing to attend the community service rather than attending the hospital. From the launch of the initiative to the end of March 2017, it was projected that there would have been 564 fewer patients seen in secondary care, a reduction of 21.8%, which is being attributed to the introduction of the community clinic. It is predicted that the service will save the local NHS more than £190,000 in its first full year.


Long-Term Conditions, Prevention and Care

Reducing Strokes – Proactive Care and Treatment in General Practice

All Rushcliffe GP practices are now using GRASP-AF – an easy-to-use tool that helps them interrogate their clinical and patient data, enabling them to better identify patients with symptoms or risk of atrial fibrillation (AF). Following diagnosis GPs can reduce the patient’s risk of stroke by starting them on anticoagulation therapy.

National data shows for every 25 patients on anti-coagulation therapy, one stroke is avoided. Based on the work undertaken to increase the number of patients supported on anti-coagulation therapy, Rushcliffe has prevented approximately 14 strokes plus the related costs – estimated at £16,632. In addition, there was an 18% reduction in AF-related strokes in Rushcliffe between 2014/15 and 2015/16.

The tool also helps identify ‘at risk’ patients earlier, giving practices more accurate data regarding AF prevalence rates within their registered population.

Principia has provided practices with Kardia AliveCor devices, which are also being used to support future AF identification, and additional training for GPs on detecting heart failure, AF and angina.


Medicines Management and Prescribing

Effective Prescribing – OptimiseRx System in General Practice

The OptimiseRx computer-based system is now being used by all 12 Rushcliffe GP practices. It integrates with current GP IT systems to deliver patient-specific messages at the point of care that ensures appropriate, cost-effective prescribing. This supports GPs and advanced nurse practitioners (ANPs) with prescribing decision-making through the provision of best practice and safety information as well as guidance on efficient prescribing.

Medicines management cost savings through the implementation of the OptimiseRx prescribing support system are predicted to be £160,000 in the first year – representing a return on investment of 300%.


Electronic Access to Medicines Information – Improving Safety in Care Homes

The Electronic Medicines Administration Record (eMAR) system has been rolled out in two Rushcliffe care homes as part of an evaluation pilot. This allows care home staff to electronically view the regular medicine regimes of residents – detailing the medications they need and when they need them. This helps medicine rounds become simpler and quicker and improves safety through reduced risk of administration error. The initiative is being delivered in partnership with the University of Nottingham, who will undertake evaluation of the impact data and outcomes.


Medicines Management – Improving Quality, Effectiveness and Efficiency

The CCG’s Medicines Management Team has continued to provide a service within Rushcliffe GP practices to deliver both cost and quality outcomes. The programme includes the provision of training, education and professional/technical support to the medicines management facilitators located within each practice.

The benefits of this service include practice-based staff having designated time allocated to medicines management, specific training and education to deliver effective outcomes and additional capacity and support from the CCG to address medication and prescribing issues.

Provision of this service allows the introduction and spread of sustainable, effective medicines management practice – particularly three key areas which are: specific drug management systems within practices, patient safety and reduction in medicines waste. This has enabled a quality service offer to patients and to be delivered within the allocated prescribing budget.


Care of Older People

Community In-Reach – Improves Transfer of Care for Older Patients

Principia has worked with colleagues at Nottingham University Hospitals Trust (NUH) and community providers to speed up the discharge of Rushcliffe’s older patients from hospital. This innovative in-reach programme sees a community matron and GPs working on Health Care of Older People (HCOP) hospital wards to ensure that older people who are medically fit to leave hospital can do so as soon as possible with the appropriate support provided to them at home or in the community.

This initiative is not only helping to speed up transfers of care but also aims to reduce future emergency admissions of older patients – providing learning for primary and community care teams on how an initial emergency admission might have been avoided.

Data also suggests that readmissions to hospital of Rushcliffe patients aged over 65 have been reduced by around 9%. The five-month pilot was extended in 2016/17 to capture impact data over a longer period to ensure robust evaluation and provide an evidence base for future service design, including the potential for roll-out across neighbouring CCGs.


Enhanced Support to Care Homes – Reducing Hospital Admissions and A&E Demand

A national study by the Improvement Analytics Unit (IAU) published in March 2017 showed that Rushcliffe’s enhanced package of support to care homes is likely to be a key contributing factor in reduced A&E attendances and hospital admissions. The IAU focused its statistical evaluation for NHS England and the Health Foundation on assessing the impact of the enhanced package of support provided by Principia.

Comparing data from Rushcliffe care homes against data from similar care homes elsewhere, the study found that those receiving Principia’s enhanced support model of care attended A&E 29% less frequently than similar care home residents in other parts of the country and were admitted to hospital 23% less often.

Principia’s enhanced care package includes having a designated GP practice aligned to each care home. This improves communication and information sharing with care home staff and consistency of care and case management through regular visits to the home. The model also sees in-reach to care homes by integrated community nursing teams, provision of independent advocacy and support for residents and care home staff having a better understanding of the services available as alternatives to ambulance call-out. Regular medication reviews and comprehensive geriatric assessments of all new care home residents have also improved the safety and quality of care provided.


Mental Health Services

Psychological Medicine – Supporting People in the Community

Principia worked with Nottinghamshire Healthcare NHS Foundation Trust to develop a new Primary Care Psychological Medicine (PCPM) Service which launched at the beginning of September 2016. Provided from Castle Healthcare Practice, the service aims to promote the equal importance of mental health with physical health, providing emotional and psychological support to people living with long-term conditions.

A team of health professionals provide assessments and signposting to support based on individual circumstances and need. In many cases this involves creating a care plan with personal goals around health management, medication and linking in with local projects or support groups. The service supports people in looking after their health and wellbeing, managing conditions, pain or symptoms better and improving socialisation and quality of life.

The PCPM service was invited to present its model at a Kings Fund Learning Network event in London in March to share learning with CCGs and clinicians from across the country.


Community Clinic – Providing Anxiety and Depression Support

A new community clinic for patients requiring or seeking additional support and advice around the treatment and management of depression and anxiety was launched by Principia in early 2017. The Depression Advice Clinic, based at Castle Healthcare Practice in West Bridgford, takes referrals from all 12 Rushcliffe practices. Teaching and training is also being provided to practice nurses regarding the benefits the service offers and the criteria for referral into the clinic.


Urgent and Emergency Care

EMAS Community Car – Reducing Ambulance Call-Outs

Data from the East Midlands Ambulance Service (EMAS) during 2016/17 showed Rushcliffe was consistently in the best performing of all 22 CCGs in the East Midlands region for non-conveyance to hospital following an ambulance call-out. This is being achieved through a number of initiatives ensuring responsive community services are in place with the capacity to support patients at home or in the community without the need to go to hospital.

Falls have historically been the reason for many 999 ambulance calls, particularly for frail older people who have fallen or slipped to the floor and are unable, or find it difficult, to get up. In Rushcliffe alone there are around 4,000 EMAS-attended falls incidents each year. Many of these patients do not require transfer to hospital and can be safely managed through community support.

A recent initiative has seen Principia working with East Midlands Ambulance Service (EMAS) to provide a community car to respond to appropriate 999 calls. EMAS community car technicians work closely with primary care and community health teams to put in place the treatment and support needed to keep patients at home – reducing the number of patients transferred to hospital where appropriate and safe to do so. New inflating cushions have also been provided to community car responders, allowing them to single-handedly support patients to a raised, seated position following a fall without the need for an additional ambulance crew to attend.


Patient Activation and Health Promotion

National Support – Empowering People and Communities

Principia was chosen as one of nine ‘intensive sites’ in the country to take forward the national empowering people and communities agenda at pace by NHS England’s New Care Models Programme. The initiative provides additional support to vanguards in delivering two key areas:

  • Building public health through community engagement – through disease prevention and the offer of non-clinical community support for patients
  • Support self-care and patient activation – supporting people with long-term conditions to manage their own health and wellbeing enjoy a better quality of life.

The ‘intensive sites’ will share learning and development opportunities with each other and identify key areas of best practice that can be spread to other areas.


Partnership Working

The Sustainability and Transformation Plan (STP) for Nottingham and Nottinghamshire – Spreading Principia Models of Care

The CCG is a key partner and contributor to the Sustainability and Transformation Plan (STP) for Nottingham and Nottinghamshire. The draft STP, one of 44 nationally, was published in November and since then local people have been invited to provide feedback on the strategic direction outlined in the plan and its five priority areas.

As part of the ongoing engagement and involvement of local patients, carers and the wider public, a series of public events was held across the City and County to listen to people’s views on the draft plan and capture feedback to inform future development and subsequent STP submissions. Examples of MCP service development were used at the events to illustrate how wider roll-out of these successful initiatives could ensure efficiency and sustainability across Nottinghamshire.

The MCP also participated in a workforce modelling initiative with its STP partners using a national tool from Health Education England. The tool combines local data, analysis and dynamic modelling to help commissioners and providers understand the future size and skill set that will be required within the STP-wide health and social care workforce.


Single Point of Access – Integrating Health and Social Care

A new approach to integrating health and social care across Rushcliffe was presented to the Nottinghamshire Health and Wellbeing Board in September. Plans include streamlining current pathways and referral routes to ensure that patients and service users are assessed holistically for ongoing health and care needs through a single point of access. The Board welcomed and supported the development of this model which aims to reduce duplication and fragmentation within the system as well as to improve the experience of care and outcomes for patients and service users. A comprehensive work programme has since been developed and agreed between local health and social care partners and will be achieved during 2017/18.