High Integration, Low Complexity example

A large inner city practice, with a demographic that mainly caters towards working age adults and families, but with some deprivation. Relatively low levels of home visits, but substantial same day demand. Part of a PCN within a group of practices that have a range of different challenges. Adequately staffed in terms of GPs, but substantial on-the-day acute demand has meant a variety of triage and appointment models have been trialled to try and balance pre-bookable availability with same-day capacity.

The practice has recently established a dedicated urgent care team to focus on same-day demand needs. The practice directly employs a full-time paramedic as part of this team, to see same day minor illness and injury. The paramedic, an advanced nurse practitioner (ANP) and the duty GP work closely together as part of the urgent care team to triage and manage the high volume of acute work, and can share and discuss cases as needed. The paramedic role is primarily to assess minor illness and single acute new problems in otherwise uncomplicated presentations. The paramedic has some exclusions, including children below 2 years, mental health presentations and health problems during pregnancy. The paramedic is working towards non-medical prescribing qualification, but manages a substantial proportion of the contacts with self-care or minor illness advice, and can call upon the GP in real-time to support prescribing activity if needed. The paramedic works from a shared ‘duty’ list and is based in a consulting room next to the duty GP. The paramedic undertakes telephone assessment, online/video consults for minor illness, and sees same day walk-ins and cases triaged to a face-to-face. Occasionally the paramedic will assist with appropriately triaged home visits, although the GP team still undertake the majority of these on account of the higher complexity of patients needing visits at this practice. The focus on remote consultations means patients can get access to acute advice quickly and flexibly, during the working day.

The paramedic has taken some time to develop in the role, as the high-volume throughput of clinic-based minor illness is quite different from the work in the ambulance service. The urgent care team has therefore taken a little time to embed and realise efficiencies. Patients are generally satisfied as the capacity to be seen for minor or acute problems ‘on the day’ has increased, which has improved access to practice services. Having all same-day problems channelled through the urgent care team is now an established and accepted model.

The GP team have needed to invest time and resource into supervising and cross-skilling the paramedic, but feel this has been worthwhile as the model is now working efficiently, and the practice are keen to further invest in developing the paramedic as a trainee Advanced Clinical Practitioner and non-medical prescriber. The practice have noted a slight increase in tests and referrals, but anticipate this will reduce with growing paramedic competence and confidence, and aim to trial removing some of the ‘case exclusions’ at some future stage. GPs tend to see less simple minor illness or single simple problems, and have noted their workload is now tilted towards higher medical complexity cases, including more mental health.