Low Integration, High Complexity example

A medium sized, semi-urban practice on the coast that is comprised of a single, busy surgery site that offers a full range of primary care services. The local demographic is divided between younger families (with some coastal deprivation) and a large quota of retirement and residential/nursing homes. The practice is part of a PCN with six other similarly sized practices in the surrounding coastal towns. Each practice has allocated a number of residential and nursing homes for which they have primary responsibility under the Enhanced Health in Care Homes Direct Enhance Service (DES). Telephone and visit requests from the care home settings place a substantial strain on the capacity of the GPs, as it is not usually possible to adequately manage these using remote/video consultation alone.

The PCN uses ARRS funding to employ three paramedics shared across the PCN sites, to provide the bulk of responsive care to the nursing and residential homes under the DES. A frailty advanced practitioner provides the day-to-day supervision. The paramedics work ‘virtually’, basing themselves out of office space in each of the practices on rotating days. Reception directs all visit requests for nursing and residential homes to the paramedic team first, and only adds to the GP list if the paramedic team have reached capacity for the day. All clinical cases are seen and assessed by the paramedic team first. The majority of cases are managed entirely by the paramedic team, who are all non-medical prescribers and have admitting rights to the local acute hospital. Cases can be discussed with a duty GP if needed, although this rarely takes place. The paramedic team undertake some ‘ad hoc’ QoF target work, and deliver the seasonal/rolling vaccination programme (‘flu, shingles, pneumococcus etc).

The nursing and residential care staff have got used to seeing the paramedics and have built a relationship with them, and accept that paramedics rather than GPs will likely be the first point of contact when requesting input from the surgery. The majority of care is recognised to be ‘reactive’, but they can always get a visit when they think it is necessary. Some patients (and their families) do not completely understand the role and remit of the person seeing them, and may miss contact with the GP, but accept that this way of working means they can usually be seen the same day when there is a serious problem. Patients who attend the surgery don’t notice much difference, although the younger families report it is slightly easier to get a GP appointment if needed than it used to be.

GPs feel they can manage the care (particularly the acute care) of their nursing and residential home patients more efficiently this way, only getting involved when very complex problems arise that cannot be managed by the acute visiting team. GPs don’t necessarily have a close day-to-day relationship with the individual paramedics, but are reassured by the prescribing audits and case reviews that they undertake periodically to ensure the safety and effectiveness of the service. GPs perhaps feel a little more distanced from the residential and care home patients, although this is offset by not needing to attend the homes so frequency for lower complexity/lower acuity problems. Paramedics are comfortable assessing patients in the care home setting as this is familiar to them, and in making admission decisions if needed, which they handle autonomously. Paramedics look to the frailty nurse and/or GP for support around chronic disease management, or for less acute health needs.