High Integration, High Complexity example

A medium sized semi-urban practice with a mixed demographic of mainly older adults including some residential and nursing home patients. The practice is a member of a PCN which includes a range of medium-sized practices that span a mixed urban area, each serving slightly different demographics. There are some challenges with GP recruitment and retention in the area; this is a regional rather than local issue. The PCN has been experiencing challenges with higher-than-average unplanned hospital admission rates across the network, and has been exploring ways of working more closely with a range of extended community offerings delivered in partnership with the PCN, including virtual wards.

An experienced paramedic who is an Advanced Clinical Practitioner (ACP) and non-medical prescriber is employed by the PCN to work at a single practice site with the highest unplanned admission rates. The paramedic is employed to lead the practice’s frailty service, which includes planned care visits to the local residential and nursing homes, and an acute visiting service. The paramedic holds a frailty caseload, working in partnership with the community nursing staff, the nursing home staff (where applicable), and the community older adult psychiatry services. The paramedic leads on QoF for patients in nursing and residential settings. The paramedic contributes to the duty rota, functioning in a role similar to the duty GP on these days – triaging, consulting remotely where possible, and bringing patients into the clinic for face-to-face assessment. There is an allocated GP for supervision, although the GP doesn’t usually need to discuss more than the occasional case.

The paramedic attends the weekly PCN multi-disciplinary team (MDT) meeting, to input into the management of the frailty caseload. The paramedic also attends the practices weekly clinical meeting and monthly palliative care planning meeting with the local hospice.

Relationships have been built up between the paramedic and the other community services, such that the paramedic is seen by other external professionals as part of the wider GP team. Patients value the continuity and the proactive case management, although some patients miss the regular contact with the GP and would probably prefer to see the GP, but understand the reasons behind the service.

The model does create some reliance upon the paramedic as an individual ‘single point of potential failure’. During annual or sick leave periods the GP team need to cross-cover and are aware that this can feel an additional significant pressure. There is also some concern amongst the practice partnership team that if the individual moves on, a significant amount of skill and experience will be lost that will be difficult to replace. The practice did have to search for a while to find an appropriately skilled, qualified and experience practitioner to join the team, and didn’t realise substantial employment cost savings over recruiting a salaried GP.