Low Integration, Low Complexity example

A medium sized, semi-rural practice that is comprised of a main, busy surgery in the town centre and two small ‘satellite’ clinics that provide limited services for some of the week. The practice is one of several similar in a PCN. Due to the rurality, patient demographics and poor transport links, the practices in this area are all very ‘high visiting’ with notable demands on GP time away from the surgery premises, particularly for ‘on the day’ home visit requests for acute problems. They have been struggling to meet the demand for visits whilst maintaining other services, and often ‘bump’ acute visit requests to the quieter mid-week period where possible, leading sometimes to a backlog and some very busy, long days.

The PCN uses ARRS funding to employ two paramedics across the PCN sites, on a shared basis, to undertake home visits as they come in. The paramedics work remotely from the practices in a central hub alongside the community nursing team, and receive allocations from all of the practices when home visit requests are received, after being triaged as suitable for paramedics by the GPs. The GPs will generally exclude end-of-life care, or high complexity cases where they have an ongoing relationship. Routine, chronic disease management for the housebound is managed by the nursing team.

Workload is allocated on a pooled basis, with no fixed quotas. Paramedics undertake, on average, 8 visits each during the course of the working day. They enter their notes onto the shared record system (including clinical photographs if needed), and are able to electronically ‘task’ the GPs to request routine bloods or make referrals, or prescribe routine medications (thus there is no need for them to be prescribers). They undertake some simple QoF activities if they are due during their visit, but focus mainly on the acute problems behind the visit request.  Each surgery has a designated GP for case discussion (which varies each day with the duty list), and the paramedic can contact them by telephone via reception. Paramedics will discuss most of their cases with the designated GP at the end of the day to have their treatment plans ratified.

Patients like the fact that they are usually seen on the same day that they request a visit, and that the paramedic can spend more time with them than the GP (which used to feel quite rushed). In general, patients feel that waiting times for home visits has reduced, although Mondays and Fridays are still busiest. Those with high visiting needs have become used to seeing the paramedics and are generally satisfied, although sometimes miss the regular contact with the GP, speaking with them mainly by telephone now (if at all). Patients sometimes have mixed feeling when paramedics go away to discuss their case with the GP – some feeling slightly less confident overall in the plan, others feeling reassured they have this safety mechanism in place.  Patients who attend the surgery in person are not really aware of the changes and have no particular feedback.

GPs have usually at most one or two visits to undertake each day, which feels more manageable. They continue to see very complex or end-of-life care cases. Paramedics feel that the clinical assessment of patients in their own homes is a familiar skill set to the ambulance roles they left, identifying if acute pathology if it exists, and discussing other cases with the GPs. They feel less confident with routine or complex care, but can discuss these cases or task the GPs for follow up when they have excluded new acute serious health needs. GPs are aware they need to allocate time each day for these discussions, and that they will need to support risk-management decisions.