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A rural revolution: GPs pioneer community-based service

River Eden
BRIDGE OVER TROUBLED WATER: The river Eden in Appleby

Exhausted and frustrated GPs in Cumbria have embraced a care scheme that promises to put the future of the NHS in their hands. Peter Blackburn reports

With just 3,000 residents Appleby-in-Westmorland – a village most famous for its annual ‘horse fayre’ – seems an unlikely location for a quiet revolution to stir.

But here in the shadows of the North Pennines GPs are planning changes that could transform care for patients.

The Appleby Medical Practice, for so long a classically isolated rural practice dedicated to local families at the southern gateway to the Lake District, is part of one of the national pilot schemes called Primary Care Home.

They aim to develop community-based services and reduce reliance on hospital care – in a bid to breathe life into the ailing NHS.

At this point a cynical response to the health service’s so frequently used buzzwords such as ‘community-based’, ‘integration’, ‘transformation’ and ‘reducing hospital footprints’ would be easy enough to justify.

After all, these hollow messages of change have rained down from politicians and NHS management for years, but instead of modernising and progressing, the health service has only become more complex, and increasingly stretched – particularly thanks to a lack of funding and a failed top-down reorganisation in the 2012 Health and Social Care Act.

But in this case doctors appear to have reason to believe forces of change far more tangible are at work.

Cumbria doctors at seven practices, including the Appleby Medical Practice, have been given the freedom to plan and make the changes – including keeping hold of every penny they save.

And in an NHS so desperately cash-strapped what could be a more significant signal of intent?


Silver bullet

Government penny-pinching and soaring demand have hit hard in Cumbria.

Many areas of the county are feeling the burden of the childhood obesity crisis and other areas are unable to cope with cuts to social care.

But these GPs now have some of the tools to tackle their problems – even if the sort of ‘silver-bullet’ funding many would like is unlikely, under the current austerity Government, to be forthcoming.

GP Ashley Liston (pictured below) has left his surgery in Washington, County Durham, to become part of the Primary Care Home project, taking up a position at Appleby Medical Practice.

Ashley Liston, GPDr Liston, who already has a time-share holiday let in the Eden Valley, was central to developing a new GP federation in the north-east of England and already brings a host of plans, including some put into practice at his former surgery, which could help to make an impact locally.

He says: ‘We brought in a rapid-response telephone consultant in Washington. Patients phone up and within 15 minutes a GP phones back and has a chat if needed. Where they need to be seen they are seen on the same day but 60 per cent of the things are solved on the phone to everyone’s satisfaction.

‘It’s a radical change in access and patients absolutely love it. Not only that but the project has resulted in at least a 20 per cent reduction in attendances to emergency care – not only do patients get better service including fantastic access to your own GP it’s having a bigger impact.

This is quality progress – it’s the absolute opposite of that common problem of a patient phoning 111 and then having an ambulance called out unnecessarily.

‘The problem, however, is at the moment we don’t benefit from that progress in the way we should. But in Primary Care Home I can access that benefit [the money saved] and I could be paying for a nurse practitioner or two or three with that.’

Dr Liston also has longer-term missions for his new parish.

‘There’s no reason a Parkinson’s or diabetic patient should ever have to go to hospital,’ he says.

‘We want a primary care-based solution here – with specialist nurses in the community. The benefits would be huge – not to mention the money saved.

‘And we need to develop imaginative teenage health services, getting into school. I also think GPs need to step out of the consulting room to deal with men’s health issues.

‘You have to start with simple solutions that result in quick wins and let everyone gain confidence. Then the more exciting long-term projects like this work in the community can begin.’

The Primary Care Home scheme was designed by the NAPC (National Association of Primary Care) as a method of allowing GPs to design a better way for services to work in local areas, with groups of practices covering around 30,000 to 50,000 patients.


Budget control

The model, which has been backed by NHS England as part of its NHS Five Year Forward View, features 15 pilot sites across the country providing care to approximately 500,000 people nationally. Plans are already being hatched to expand the model to reach upwards of four million people in coming months.

Each area has been given control of the health and social care budget allocated to residents.

The eventual aim for each local project, with the 15 at different stages of progress, is that care will be provided by a ‘complete clinical community’, with an integrated primary, secondary and social care workforce providing more personalised and better coordinated care closer to home.

And for Dr Liston – who has seen friends and colleagues become ever more exhausted and frustrated under a mountain of demand and a molehill of funding – the project could hardly be more exciting.

‘The reason I see it having legs is because it resonates with general practice,’ he says.

‘GPs like to feel part of not just providing the service but delivering it and organising it. But when it’s too large you lose engagement – I think that’s the problem with federations that cover big cities.

‘You need to genuinely work collaboratively and this is the challenge. This is where Primary Care Home is the real thing. It’s not just having access to the NHS funding for patients but that you can be creative with it, and become advocates for the community.

‘General practice has always meant you are an expert in the community and you give personalised care to your patients. Local GPs who network and know each other can develop services and so many other aspects – it’s exciting. You can develop education, training, clinical governance and career pathways.’

Dr Liston adds: ‘GPs are becoming interested in using the money imaginatively and thinking more about whether we need to admit, refer or prescribe or use the money in other ways. Where funding is grouped up you can make savings and do some very creative things.

‘We are getting GPs working together – we’re deciding our futures rather than having a top-down decision. We have to agree to change and have the motivation to do that.’

NAPC president James Kingsland, a former adviser to the Government on primary care, says the scheme could make a big impact.

‘Primary Care Home is about building from the registered list, which has served the NHS so well and recognises patients access the NHS through general practice. This new model of care will be more ambitious in the delivery of first contact.

‘There is a strong sense that this programme will truly be transformational in the delivery of first contact, primary care within the NHS.’

And it is a view supported by NHS England – with the health body including Primary Care Home in its transformation plans.

Chief executive Simon Stevens endorsed the project last year – and crucially gave up the funding. He says: ‘This programme offers an innovative approach to strengthening and redesigning primary care, centred around the needs of local communities, and tapping into the expertise of a wide array of health professionals.’


Bed blockers

Shonagh Speed-Andrews is one of the GPs in Cumbria putting plans into practice – and has been involved in leading action so far, including hiring external consultant support and planning between practices.

‘We’re talking about ideas that were just not possible previously,’ Dr Speed-Andrews says.

‘Nobody has very much money but at the moment we as GPs are paying for our patients in hospital beds who shouldn’t be in hospital beds and are often admitted for social reasons because there isn’t the capacity in the community.

‘In any one week the Cumberland Infirmary [in Carlisle] has between 17 and 25 older adults blocking beds not for medical reasons but because they cannot be accommodated in the community.

‘And our community hospitals are also completely blocked with social cases who do not require nursing and medical care but do not have the facility in the community. Since the council has shrinking budgets it is on us to deal with this.’

Maryport GP practice manager Sarah Cousins echoes Dr Speed-Andrews’ message.

‘It is a way of working that is much more focused on the individual patient and results in a more effective level of communication between health and social workers which is key to giving patients timely care.

‘In specific cases the consultant has made a home visit if the patient is unable to attend the practice. For the more vulnerable members of our community, such as the elderly or the very young, this has improved outcomes significantly and has also reduced hospital admissions, which of course reduces the pressure on hospitals and NHS services in general.’

These are early days in Cumbria, but change – in a more positive sense than the NHS is used to – could become a reality if these GPs can make their vision a reality.

The Primary Care Home scheme comes during a wider NHS transformation project. Last year NHS England announced 50 vanguard sites, which aim to integrate health and care services better, with each trialling different solutions to the most obvious problems facing the health service.

The pilots are part of the vision for the NHS set out in the NHS Five Year Forward View.

BMA GPs committee chair Chaand Nagpaul (pictured below) said at the time: ‘If implemented properly and led by clinicians, these models have the potential to break down disruptive organisational barriers between GP, hospital and community services.’

And some of the projects do appear to be delivering progress – in terms of patient care and financial savings – such as in Rushcliffe, Nottinghamshire, where integrated care appears to be becoming a reality. While the work in Cumbria is at a much earlier stage, one thing is abundantly clear from the lessons already being learned.

The NHS is under strain as never before, and is being made to suffer for the failings of politicians – the mounting, deadening PFI bills, the built-in fragmentation of the purchaser/provider split and a bizarre approach that hints at localism but insists on micro-management.

Doctors have never given up, but neither have they often been given the chance to make things better. In Cumbria, their opportunity may be relatively small when considered against the vast challenges the NHS faces, but it’s an opportunity they are determined to seize.

As Dr Liston says: ‘It’s about thinking imaginatively and creatively. If we do that we can start to create a brighter future for GPs to believe in.’

Vanguards of an integrated care revolution

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