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A new service is helping patients stay out of hospital by treating them at home through a community paramedic scheme.
The service was developed by Encompass in partnership with South East Coast Ambulance Service and means GPs will have more time to proactively manage patients with complex or long-term conditions.
Launched in Whitstable last spring, the service was rolled out in Faversham, Canterbury, Ash and Sandwich in November 2015.
The programme sees teams of community paramedics undertaking some of the urgent GP home visits on behalf of surgeries. And, on average, they are visiting more than 100 patients per week.
GPs determine which patients are suitable for a paramedic visit, allowing the patient to receive a quicker response and GPs to focus on seeing patients in their surgeries.
The job of the community paramedic is to help an ageing population stay out of hospital and remain independent, thinking about patients’ mental wellbeing as well as their physical health and working closely with GPs and other primary care providers to create a more joined-up service.
Dr Jacky Buchanan, from Whitstable Medical Practice, said that community paramedics can often see patients quicker during the day, in the morning when a GP would not normally visit until the afternoon, which frees up GP time to see more patients with complex or long-term conditions.
She said: “The paramedics are able to quickly asses and treat patients who have more straightforward conditions, such as those who have had a minor fall or chest infection.
“This means that GPs can become more proactive by visiting patients with long-term conditions and making sure they have what they need before they request a visit.
“The scheme will change the way a GP service works, from being less reactive to more proactive. Hopefully by doing this we can try and prevent problems from becoming a serious issue or a crisis, avoid the patient having to go to hospital, and giving patients better overall care without unnecessary stress or discomfort.”
Whitstable community paramedic Steve Hulks said: “Working alongside our GP and community service teams in this way, you feel part of a whole team working together for the benefit of the patient.”
Dr John Ribchester, Encompass Chair and Clinical Lead, said the scheme was a good example of transforming care locally. He said: “The figures have been impressive and we expect it will prove very successful.
“Since the programme was rolled out, the community paramedics have been seeing between 100 and 130 patients per week. Patient and staff feedback has been incredibly positive and early indications show a reduction in the number of patients being taken to hospital.
“In a survey, 100 per cent of patients asked said they would be completely happy to see that paramedic again. More than 80 per cent of paramedics feel integrating with GPs has increased their primary care confidence, and 75 per cent feel they have been able to provide a better service to the community and patients.
“The team also dealt with the referred 999 calls in the area and the transfer to A&E was also down, so it has been an excellent start.”
This new way of working will mean that patients can receive more of their care from their local surgery, without the need to travel to hospital.
Original post by Canterbury NHS
Original post by Neil Roberts - gponline.com - 09-02-2017
One in seven practices could lose more than £8,000 a year on average from April unless they open for longer under the 2017/18 GP contract.
The 2017/18 contract announced on Tuesday introduced an additional requirement for the extended hours DES, which makes practices that close during core hours potentially ineligible for the funding.
NHS England said that from October practices that regularly close during core hours will not usually qualify to deliver the extended hours DES.
The GPC has suggested that the change will affect only a small number of practices. It said only practices that close for half a day on a weekly basis could be affected, while local exceptions may apply for branch or rural practices and for monthly training closures.
But recent figures from a National Audit Office report that prompted the government’s crackdown on core hours closures suggest around 14% of practices in England - over 1,000 practices - could be caught by the new rules. It said 18% of practices closed at or before 3pm on at least one weekday, with 76% of them receiving funding through the extended hours DES, earning an average of £8,224.
GPC deputy chair Dr Richard Vautrey said he would be ‘very surprised’ if that many practices were hit by the changes, but he said no details had yet been agreed with NHS England on defining half-day closures. ‘This is a high level agreement as it stands at the moment,’ he said. ‘That detail will need to be looked at. But the principle is everybody knows what a half day looks like and that is what we are going to be focusing on.’
‘Ultimately it would then come down to a decision for practices as to which one they chose to do, whether they continue to close,' he added. ‘This isn't forcing any practice to change their working arrangements. If they want to continue with half-day closing that will be their choice. They would have to make a decision about the cost-benefit about doing the extended hours or not.’
Dr Vautrey added: ‘This is as much about patients being able to walk in to pick up a prescription or to make an appointment at the reception desk as it is about anything else. So I think there are different ways practices can make themselves available that suits their population.
‘The NAO clearly identified a concern and I think the agreement is to try to address that but in a way that is appropriate and proportionate.’
The NAO report published in January ignited a political row over GP access. Prime minister Theresa May was accused of ‘scapegoating’ GPs for the NHS crisis after Downing Street officials suggested practices were failing to provide the access that patients need.
The RCGP has called for clear guidance on opening hours required from practices under the extended hours DES. The college warned that the deal 'must not be seen as a lever to force practices to compromise patient safety and GP welfare by opening at impractical or unrealistic times'.
A GP practice in Plymouth has reduced the time it takes to get a routine appointment with a doctor from three-to-four weeks to under seven days.
The Beacon Medical Group cares for more than 30,000 patients and was formed in 2014 after three practices merged.
Dr Jonathan Cope, GP and managing partner at Plympton Health Centre, one of the Beacon practices which has 10 doctors, says, at present, there are 30 unfilled GP posts in Plymouth.
Three years ago, his practice was unable to recruit the equivalent of one-and-a-half full-time GPs.
"We made a conscious decision to look elsewhere, to work differently. So we decided to looks at what skills clinical pharmacists, paramedic practitioners and nurse practitioners could offer. We converted that budget to two-and-a-half full-time equivalents."
Patients registered at Plympton who feel they need same-day care from their family doctor call the reception team at the surgery.
Depending on the problem, they will then be called back by an advanced paramedic, pharmacist, nurse practitioner - or a doctor.
Beacon Medical Group has started to offer new services
Dr Cope said: "Because of the extra capacity, we have freed up the GPs' time. So we are offering more appointments for routine problems, and the waiting times are now shorter."
The advanced paramedic practitioner, Simon Robinson, responds to any emergency medical problems in the practice, as well as doing, on average, four home visits a day.
He says he is often called out to see the more complex cases and his daily schedule allows him to spend more time than the GPs with patients. Simon was keen to point out that if he does have any queries he just has to knock on the GPs' door.
Prof Helen Stokes-Lampard, chair of the Royal College of GPs, said while paramedics are highly valued and trusted, they have different skills and training.
"GPs are highly trained to take into account the physical, psychological and social factor - this unique skill set cannot be replaced by another healthcare professional, however well meaning the intention is.
"We do not have enough GPs in the NHS - and actually we don't have enough paramedics either. This transference of workload pressures from one area of the health service to another is not going to benefit our patients in the long term."
In an effort to understand the pressures on the Beacon Medical Group, the 100 most frequent attendees were analysed.
Dr Cope expected the list to be dominated by frail, elderly patients but instead the typical patient was a 37-year-old woman, often with mental health problems, multiple prescriptions and referrals to hospital.
From March, a psychiatrist will do a weekly clinic from the surgery for these patients and provide additional training on mental health care to staff.
It is part of a parallel drive to offer specialised new services more commonly found in a hospital setting.
Dr Frow has provided specialist dermatology care
Dr Helen Frow, a GP with a special interest in dermatology, has provided care to patients registered to the group in the last two years. "Onward referrals to the hospital have reduced by 85%," she said.
A similar scheme for musculoskeletal care resulted in 75% fewer secondary care appointments.
The model of working with between 30,000 to 50,000 patients in a multi-specialty community provider model is known as a Primary Care Home.
There were 14 other sites working to this structure across England in the last year.
The National Association of Primary Care is working closely with NHS England to explore how they can continue to expand working in this way.
A BMA spokesperson said: "Many GP practices are increasingly becoming hubs where nurses and other professionals work together to deliver services to patients.
"However, while this is encouraging, England is suffering from a drastic and worsening shortage of GPs that is damaging patient care and restricting the number of appointments on offer to the public.
"The government needs to address this workforce crisis urgently."
The independent Primary Care Workforce Commission, established by Health Education England (HEE) in 2014, called for rapid implementation of the 10-point plan launched by the RCGP, BMA, NHS England and HEE.
The commission’s report, The future of primary care: creating teams for tomorrow, called for greater use of pharmacists, physician associates and healthcare assistants and a workforce plan for primary care nursing.
The report also called for fundamental changes to NHS funding mechanisms to incentivise integrated care across sectors.
Among its more radical recommendations the commission, chaired by professor of health services research at the University of Cambridge, Martin Roland, called for piloting and evaluation of the potential benefits of using ‘paramedics to substitute for GPs’ in the assessment of urgent requests for home visits.
Professor Martin Roland: led GP workforce commission
The report cited GPs’ excessive administrative burden as a major cause of doctors leaving the profession. It said there is ‘a case for training support staff, including healthcare assistants and existing administrative staff, to assist healthcare professionals in the administrative aspects of their work.’.
The commission, whose members included RCGP vice-chairwoman and workforce lead professor Amanda Howe, and professor of general practice and primary care at Durham University Greg Rubin, also called for practices to be organised so that a ‘significant’ number of consultations are longer than at present.
Health secretary Jeremy Hunt ordered the commision in October 2014 in response to the GP workforce crisis. Mr Hunt also pledged to take on 5,000 new GPs by 2020: a target which has been watered down in recent weeks from a minimum to a maximum figure.
While calling for the 5,000 target to be implemented, the commission recommended it be regularly reviewed.
GP workforce crisis
RCGP chairwoman Dr Maureen Baker said: ‘Professor Roland’s report could prove to be a valuable lifeline to help rescue general practice from years of neglect and under-investment and ensure that we can continue to deliver good and safe care to our patients well into the future.’
‘We welcome the Commission’s call for rapid implementation of the 10-point plan, launched jointly by the RCGP, NHS England, HEE and the BMA earlier this year to build the GP workforce.
‘While the Commission’s report is aspirational for the future of primary care, it also shows a lot of common sense, particularly in calling for a shift in funding from secondary to primary care.
‘By strengthening general practice, we alleviate pressure across the health service by ensuring that more patients are cared for close to home where care is cheaper and where our patients want it most.
‘But we recognise that general practice itself also has to adapt and change.
‘We welcome the report’s backing of new models of care, particularly federations, which the college pioneered, and which we are currently involved in mapping out across the country.
‘We are also open to widening the skill-mix in general practice, with the introduction of roles such as practice-based pharmacists to take on some of the tasks that do not necessarily need to be done by a GP.
‘These will never be a substitute for GPs so any new roles, such as medical assistants, must be properly piloted and evaluated to ensure that they can add value to patient care in general practice.’
Roland Commission recommendations:
- Short and long term plans to increase recruitment and retention. Implement the NHSE, HEE, BMA, RCGP 10-point plan and government 5,000 GPs target. 'National targets for GP numbers should be regularly reviewed. There should also be scope to adjust plans at local level providing that those plans can be demonstrated to meet local need.'
- Equivalent measures to 10-point plan for primary care nursing.
- Greater use of pharmacists in management of people on long-term medication and people in care homes.
- Wider use should be made of community pharmacists and pharmacy support staff in managing minor illness and advising people about optimising their medicines.
- Benefits from a range of new staffing approaches including 'wider use of physician associates and healthcare assistants. The potential for paramedics to substitute for GPs in the assessment of urgent requests for home visits merits further evaluation'.
- Development and evaluation of new support staff roles to tack on admin burden.
- 24-hour community nursing services should be available in all areas
- Research is needed to compare skilled versus less-skilled staff providing telephone triage in out-of-hours care.
- Practices need protected time to support team working: ‘contractual and employment arrangements for staff in primary care should include time to support professional activities focused on quality improvement and clinical governance .’
- Contracts for community nursing services and GP out-of-hours care should require bidders to demonstrate they have the ability to integrate well with other primary care providers, encouraging practice federations or MCPs rather than stand alone providers to take contracts.
- General practices should be organised so that a significant proportion of face-to-face consultations can be longer.
- Structured training opportunities should be available to GPs who wish to develop extended clinical, academic or leadership roles.