Creating an Extended Primary Care Team (EPCT) South Hampshire Vanguard Multi-specialty Community Provider

Background Many GPs have seen close working relationship with District Nurses disappear as community services became more geographically rather than practice based. Over the last years there has a move to create Integrated Community Teams (ICT) which include Community Nurses, Therapists, Mental Health and Older Peoples Mental Health and Social Care. Yet we know 90% of patient activity occurs in General Practice. To create effective teams the ICT must involve General Practice. Some studies have shown that at least 10% of work undertaken by Community Teams and General Practice are duplicated and 20 – 30% of visits are undertaken by the wrong health care profession when there is a lack of integration between General Practice and Community Services.

Why the New Forest? The SW New Forest has a population of about 70,000 and divides into two natural localities. There are two Community Teams who are based in each of the localities supported by a Single Point of Access. The challenges and perceived barriers that currently include GPs and Community Teams working from different sites, lack of face to face communications, increasing communication using electronic proformas, recruitment and retention of community staff, lack of integration of clinical records, Practice and Community Nurses working in isolation, rising workload, lack of integration with Social Services. Our aim is to provider services focused on a patient's needs.

How can care be improved? We believe this can be achieve by putting the patient at the centre of the provision of care and removing the artificial barriers that exist between General Practice and Community Teams. The basis of this programme is to develop a single team basis in a locality that has clinical and management leadership. Over a 6 month period, General Practice and the Community Teams have been working together to create a new structure that is based in a locality and has GP and Community Leadership and has been empowered to co-design a better service.

How can care be improved? We believe this can be achieve by putting the patient at the centre of the provision of care and removing the artificial barriers that exist between General Practice and Community Teams. The basis of this programme is to develop a single team basis in a locality that has clinical and management leadership. Over a 6 month period, General Practice and the Community Teams have been working together to create a new structure that is based in a locality and has GP and Community Leadership and has been empowered to co-design a better service.

What could be different? A common electronic patient record Stronger clinical leadership Improved efficiencies – reduced home visiting by Community Staff Wound Care Clinics – based in the community for mobile and the less mobile Continence Clinics Long term conditions – greater focus on delivering an appropriate service to the housebound Creation of a core team that is practice based but also the team is part of a wider locality based team.

What could be different? Better care for frail elderly at home and in residential care More confident Community Team including Practice Nurse expertise visiting the elderly - undertaking chronic disease assessments if needed and linking in to needs as they arise - not firefighting in crisis Locality based Well Leg Clinics – shown to improve the healing rates and help address social isolation. Links in with the Wellbeing Cafes run by Age UK with voluntary sector transport and social signposting.

Mental Health? Adult There needs to be a greater focus on community based mental health services. About 20% of a GPs workload is associated with mental health and they are not always the best healthcare professional to manage these patients. The MCP will allow a more integrated approach to managing this group of patients and support the sustainability of General Practice. This could include practice based mental health workers, the introduction of a crisis café and greater use of services such as the “Recovery College”.

Mental Health? Older Peoples This has focused on patients with Dementia. Locally in-patient services have moved to Southampton and we are left with a community based service. The service was seen as a single pathways designed to assess, diagnose and manage patients with Dementia. With the loss of the local in patient unit, the move to increasing the prevalence rate of dementia, with GPs making the diagnosis in certain groups of patients and the reduction in the need to monitor medication it is time to review the role of the OPMH Team and develop a far more integrated service with General Practice.

Conclusion Out of hospital care provided at scale has to start with the registered list but to work effectively there needs to be critical mass to be able to undertake the work that is needed at scale. The extended primary care team needs to be embedded in the practices but will need to be able to meet the needs of a wider population. Working as a single team does not mean a single employer but will require a share patient health record.