The changing landscape of primary care: multidisciplinary community providers

Irrespective of the outcome of the general election next month, pressures on the NHS will continue for the foreseeable future. For now, at least, the ambitious visions for the future of primary care – set out in the NHS Five Year Forward View – are beginning to deliver results. One model is the multidisciplinary community provider (MCPs). But where do general practice nurses fit in?

WHY WE NEED TO WORK DIFFERENTLY

The NHS is under pressure. People are living longer, many of them with long term conditions (LTCs) which use up 70% of the NHS budget. In addition the NHS needs to deliver £30 billion savings by 2020. There is a shortage of healthcare personnel nationally, affecting the ability to recruit to all staff groups, including GPs and nurses. The wider healthcare system is also feeling the effects of cuts in social care funding, with consequent increased demand on the health service adding to the pressure.

According to current Health Foundation modelling,¹ pay will increase until 2019, in line with the current plan for public sector earnings, at 1% a year in cash terms, and at the long-term average rate of 2% a year between 2019-20 and 2030-31. Between 2020-21 and 2030-31 the assumption is that the NHS budget will rise in line with Gross Domestic Product, estimated at 2.2% a year. It is estimated that there will be a gap of at least £70 billion between funding and health spending by 2030-31 and at least a £10 billion gap between funding and spending pressures for Adult Social Care in the same period.

The only way to tackle the gap between demand and capacity is to radically rethink how we deliver services. The NHS Five Year Forward View (FYFV),² gives a steer in that it supports the improvement and integration of services. It advocates decisive steps to break down the barriers between organisations in order to realise efficiencies, bring care closer to home and reduce the pressure on acute services. This is also the vision for the 2016 Kent and Medway Sustainability and Transformation Plan (STP),³ whose evidence base for its ‘Local Care’ work stream suggests that:

• 30% of patients in acute hospital beds would be better looked after in an alternate location of care, either in a short term or step down bed or at home with community nursing or social care support
• 12% of admissions through A&E are avoidable through more consistent decision-making at the front door, or better health and social care provision in the community
• 25% of community hospital patients would be better cared for at home or in a community setting.

THE VANGUARDS

The 2015 and 2016 NHS England New Care Models Programme has funded 50 Vanguard sites across the UK to try out new models of working.^4,5 Encompass is one of 15 MCP Vanguards. It is composed of 13 GP medical practices serving a population of 170,000. In response to the vision set out in the FYFV,² it is trying out new models of care as a blueprint for future service provision.

The Encompass model aims to address some of the issues highlighted within the STP through three main areas of focus:6

1. Integrated Case Management (ICM) for individuals with complex needs,

2. Development of enhanced services within a community setting

3. Developing clinical leadership.

The objective of its Integrated Health and Social Care model is to deliver high quality, outcome focused, person centred, coordinated care, that is easy to access and enables people to stay well and live independently for as long as possible in their home setting, and avoid hospital admission.

Encompass is a complete redesign of the way traditional health and care systems operate. Its philosophy is for services to work together to promote and support independence. The concept is the Community Hub Operating Centre (CHOC). A CHOC, based on a population of 30-60,000, delivers a broad range of integrated community services ranging from primary care, GP and practice nurse services, specialist nursing services, community nursing services, paramedic practitioner services, health prevention and promotion services and voluntary and community services. The emphasis is primary care, linking together around the CHOC population to maximise existing resources and increase efficiency. Other services are wrapped around this defined population and, by incorporating other non-traditional services, will increase capacity and utilise the skills of scarce professional staff appropriately, especially nurses and doctors.

INTEGRATED CASE MANAGEMENT (ICM)

The emphasis is on embedding ICM for complex patients (those with one or more LTCs, adults of all ages), which is person centred and focuses on anticipating, and mitigating for, the triggers of failing health. The ICM plan of care is developed to enhance people’s lives at home and to prevent hospital admission, with an intensive multi-disciplinary team (MDT) approach for a specific time period. The CHOC ICM Team comprises:

• GPs
• Community Nursing
• Specialist Nursing
• Intermediate Care
• Health and Social Care co-ordinators
• Adult Social Care
• Community Mental Health (younger and older adults)
• Social Prescribing (Encompass is working with Red Zebra, an umbrella organisation for 360 voluntary and care agencies).

Patients are put on the CHOC caseload as a ‘step-up’ for an intense period. The MDT will develop an integrated care plan, which will have taken into consideration the medical and social care actions that need to be in place to avoid hospital admission. Once the care plan is in place and actioned, individuals will move back to the normal MDT, freeing up capacity to focus on another patient.

Case identification

For the initial proof of concept stage, to test out the model, the GP risk stratification data was used to identify the caseload for the CHOC ICM process. This is evolving; it soon became apparent that the skills and expertise of the specialist LTCs nurses were vital as the key individuals to drive this process in the future, and to be the key point of contact for patients.

Data sharing, consent and governance

The ICM process provides a platform to share and update vital patient information to prevent hospital admission should the patient/carer experience a crisis. Therefore patients must consent to this process, as their data is shared across the different organisations. Data sharing agreements must be in place between organisations to ensure information governance is robust.

The MDT meeting

The ICM MDTs are held weekly. The care plan is pre-populated beforehand, with the known information from the GP system, to make the process quicker. This is where the LTCs nurse role is vital, as they are likely to know the patient and can have the conversation with them to define their goals and wishes.

The meeting provides access to a pool of expertise and skills, allowing identification of the gaps in care that can then be added to the care plan. These gaps would have previously been undetected and ignored.

The patient must agree with the care plan, giving them individual ownership of their health and wellbeing.

The added value of social prescribing

Social prescribing is a way of linking patients in primary care with sources of support within the community. It provides health and social care professionals with a non-medical referral option that can operate alongside existing treatments to improve health and well-being. It aids identification of other areas for action, such as anticipating carer breakdown and or social care issues which, if not addressed, may lead to the need for hospital or care home admission.

Shared communication

It is important for stakeholders to share and contribute to the care plan. The Medical Inter-operability Gateway (MIG), which will give read/write access to electronic records across all organisations, is not yet complete and Encompass needed an interim solution. This has been put in place using the GP EMIS system. Key individuals from partner organisations have remote access to patients on the CHOC caseload, in order to update any actions. This then feeds back into the GP system so that the GP has an up-to-date record of anyone involved in the patient’s care plan.

Part of the remit of the Vanguards is to share learning. The Encompass care plan template is being used for MIG development as the care plan for east Kent, and currently can be viewed by ambulance and out of hours providers.

ICM Outcomes

The Centre for Health Service Studies at the University of Kent is supporting the Vanguard with quantitative and qualitative evaluation. The results are expected by the end of 2017. However, early indications show:

• Increased patient satisfaction – patients feel more confident to self-manage and know who to contact if they need support and advice
• A reduction in patient appointments, hospital admissions
• Staff feel their patients are getting better quality and more holistic care
• An increased use of the voluntary and care sector – the highest area of referral to date is for befriending services to deal with social isolation
• Improved safety, with out of hours providers able to view the care plan.

Next steps

Encompass is now expanding the CHOC ICM process, linking in to a local initiative ‘Home First’, not only to stop people going into hospital but also, by allowing in-reach to A&E, to stop ward admission and to advance discharge where possible.

Next year (2017-18) Encompass will be introducing video conferencing facilities to make the ICM meetings more efficient and reduce travel time. It is also looking to expand its focus to include children with complex needs.

DEVELOPMENT OF ENHANCED SERVICES

The Kent and Medway STP focus on developing local care, with a shift of resources from Acute to Community Care, has given Encompass an opportunity to look at building on the integration of community and practice nursing services across specific service pathways related to continence care and wound care. These were identified as service pathways that, with the utilisation of existing services, offered clear opportunities to provide joined up delivery across primary and community nursing teams, thus reducing demand on secondary care.

Catheter clinics

Using the skills of the Kent Community Health NHS Foundation Trust (KCHFT) community nursing teams, practice nurses from three CHOC localities were trained in catheter care. Emergency catheter clinics were opened in April 2016 for ambulatory patients. The early caseload identified areas of development in relation to patient flow from East Kent Hospitals University NHS Foundation Trust (EKHUFT) and work has been completed with them on developing the catheter pathway.

Patients fitted with a catheter in EKHUFT, now leave with a catheter ‘passport’ and advice on where to go for any catheter related issues. Housebound patients continue to be seen by the community nursing teams at home, but ambulatory patients with catheter problems can go to one of three sites across the Encompass footprint. Community and practice nurses now work to the same level of competence, using a shared protocol, to support the new catheter pathway.

The Catheter Clinics are showing some encouraging outcomes:

• Consistency of training and competency for nursing staff across primary and community teams
• Ease of access within a community setting for ambulatory patients with catheter related concerns
• From April 2016-January 2017 a 29% reduction in A&E attendances for catheter related issues
• On track to reduce acute admissions by 224 through the provision of emergency access for catheter related problems in community settings rather than through A&E attendance.

Wound medicine clinics

KCHFT have developed a successful Wound Medicine initiative. This aims to standardise wound care practice through the introduction of specialist wound medicine centres and the use of innovative software to track and trace wound healing rates, as well as advice and guidance on wound dressings. This initiative resulted in:

• The setting up of multi-professional wound medicine clinics (nurses and podiatrists)
• An increase in wound healing
• A reduction in wound infection rates
• Greater levels of consistency in wound medicine practice
• Increased patient satisfaction.

Building on this, joint Task and Finish Groups were established to oversee the development and operational rollout of integrated wound care across primary and community teams, so that patients would have the same consistency of practice and quality of care. A joint Tissue Viability and Nursing Integration learning session was held for practice nurses, healthcare assistants and prescribing administrators. Work was undertaken to bring together policies and standard operating procedures for community and practice based staff, and practice nurses were trained to use the new wound medicine software.

A GP practice wound medicine clinic is being currently rolled out in each CHOC locality, with results to be evaluated in 3, 6 and 12 months. Initial outcomes achieved include:

• Consistency of training and competency for nursing staff across primary and community teams
• Consistency of practice using specialist wound medicine software
• Integrated standard operating procedures and policies across primary and community teams
• Shared learning, with access and support for practice staff, to specialist tissue viability specialist services for complex wounds.

Specialist nurse led group psycho-education

As part of embedding parity of care provision for those suffering from long term mental health disorders with those suffering from physical illness, the development of the community mental health workforce will also be a critical element of the integrated nursing team at a CHOC level. There are a number of initiatives already in place for elderly mental health and Encompass will be supporting this with dementia cafés and support for carers.

Encompass is also looking to pilot group sessions for patients with bipolar affective disorder and psychotic disorders including schizophrenia, schizophreniform delusional disorder, and schizotypal personality disorder. It has been shown that clients who engage in group psycho-education have improved concordance with medication.⁷ Group psycho-education can also reduce recurrence and hospital admission in people with bipolar disorder.⁷

Rollout of the specialist mental health nurse programme began in February this year with the aim of:

• Reducing symptom severity
• Increasing time between relapse episodes
• Improving medication concordance and self-management
• Identifying early warning signs of changing mood states
• Reducing A&E attendances.

DEVELOPING CLINICAL LEADERSHIP

The vision described in the local STP is a reduction in acute in-patient beds by 300, with a shift of activity into the community. This will also mean a shift in workforce, many of whom are nurses and healthcare assistants. There is also a need to focus on preventing hospital admission and the initiatives above describe some of the ways Encompass is supporting this aim. However, people will become unwell and we need to develop a workforce with the right skills and competencies to be able to intervene rapidly to help individuals avoid going into hospital.

Encompass has discussed this need with partner organisations and is commencing a programme of investment in clinical leadership and development for nursing staff to support them in taking on more advanced clinical leadership roles to support GP practices around a CHOC population of 30-60,000.

In order to support the development of clinical leadership, next year Encompass will:

• Re-focus the LTC nurse role to drive the CHOC ICM process
• Invest in the development of existing nursing and Allied Health Professional (AHP) staff to take on Advance Practitioner roles (with ability to prescribe)
• Invest in leadership development training to support the change process for clinical staff (especially with the move from acute to community roles)
• Invest in other staff groups to take on some of the existing tasks, in order to free clinicians to take on more advanced roles, (including introduction of assistant practitioner roles, increasing the number of health trainers, introducing more pharmacists and pharmacy technicians into primary and community teams.)

It has already been found that the LTC nurse is key to achieving truly integrated care for individuals with complex medical and social needs. This is why Encompass is actively seeking to realign the existing role of the LTC nurses as a key driver of the ICM process. Their expertise in management of complex patients puts them in an ideal position to ensure that everyone on their caseload has an integrated, anticipatory care plan. Not only is this good for patients but is an exciting opportunity for nurses to expand and develop their role.

CONCLUSION

The Encompass CHOC model is supporting care closer to home. GP practices are working around the larger populations served by a CHOC, with the advantage of being able to pool and share resources. Integrated working across organisations and the development of single care plans for complex individuals is providing more holistic joined up care. Work to date has shown that nurses and AHPs are key to driving the change needed. However, they are a scarce resource and need to be deployed wisely.

There is willingness for service redesign and role development but this requires investment and time. Encompass understands this change model requires identified provision for clinical leadership development and a robust workforce plan if services are to become more community focussed.

If nurses and AHPs are to take on more advanced or different roles, there needs to be new thinking about integrated workforce requirements, across health, social care, the voluntary and care sector, in order to release capacity for them to do so.

Changing landscape provides world of opportunities for practice nurses

Dr John Ribchester

Chair and Clinical Lead, Encompass MCP Vanguard and Executive partner, Whitstable Medical Practice

If you had to sum up what it means to work in one of the new integrated MCPs or vanguard practices, it is the difference between working as part of a well-connected team and working in isolation in disconnected silos. It is better for the healthcare professionals, and it is better for patients, because of the opportunities to co-ordinate care, and to avoid duplication and omissions.

Already we are seeing comments from nurses and nurse managers that working together in local teams serving populations of 30-50,000 patients is leading to the development of better personal relationships between practice and community nurses, and greater levels of professional trust – so, for example, you can trust what someone else has written in the patient’s records. And this is better for patients who are cared for by smaller numbers of people, with a care co-ordinator, rather than being passed from one sector to another.

The traditional practice nurse does all the usual treatment room and QOF work but in the new environment that is changing – and she can become a care co-ordinator, or an educator, or a specialist clinician or a manager.

Working in a larger group also presents increased opportunities for education and study, and for those who are interested in it, opportunities for research.

Our practice nurses include one who is an emergency nurse practitioner (ENP), who leads a team which includes several other ENPs, paramedics and healthcare cassistants. She has developed a forum with nurses working in local minor injury and A&E departments, to run study afternoons, share information, and develop protocols that we can all use – rather than each practice developing their own.

CAREER DEVELOPMENT

There are also chances to develop a portfolio career in a larger group: in a smaller practice, while you may have an interest in pursuing a specialist interest in – say – respiratory nursing, there may not be the patient numbers to make it worthwhile, whereas in a larger group there is much more value in someone developing a specialism in an area relevant to the patient population, and being able to practise it every day, in a large enough population to make it possible to carry out audit.

For example, our fracture clinic nurses started off with limited involvement with patients with minor fractures, and now deal with cases from diagnosis to discharge. Our dermatology specialist practice nurses, who work with a consultant dermatologist and GPwSI, now do biopsies and so on.

It is a much richer environment than conventional general practice.

There are advantages to working as part of a larger team – for example, one of our nurses has become an educationalist, another does the rotas for all the practice nurses and healthcare assistants making it easier to arrange cover in the event of unexpected absence.

In a bigger group, it is easier to ensure that nurses have an annual appraisal – and to follow it through so that learning objectives and personal development goals are pursued, whereas is a smaller group you often have to keep running just to stand still.

We are also finding it much easier to recruit and retain our nurses. General practice is often perceived as very isolating – you have fewer colleagues, and you don’t see much of them. There is a sense that if you go into general practice nursing – perhaps to avoid the out of hours commitments of hospital nursing – that the end of it: it’s a cul de sac. But it is not like that in a larger group – there are opportunities to diversify, to learn more, to develop your career, to become a manager.

Working in a larger group of practices can also be financially rewarding. As practices merge and average list sizes increase, TUPE (Transfer of undertakings regulations) applies – so the salaries of the lowest paid practice nurses have to be brought in line with those who are better paid. And I believe that the more nurses do, the more they should be valued. In a bigger group you can lobby for an increase in salary if you undertake additional duties, and enjoy enhanced remuneration for taking on an enhanced role.

But what about nurses who work in practices – and there are some which have not engaged with change – that are not part of a federation or larger group? My advice would be to get into a discussion with the practice, the practice manager or the senior partner, about where they see the practice in five years’ time. It is a changing world out there, and there are opportunities if you embrace them.

If you had to sum up what it means to work in one of the new integrated MCPs or vanguard practices, it is the difference between working as part of a well-connected team and working in isolation in disconnected silos. It is better for the healthcare professionals, and it is better for patients, because of the opportunities to co-ordinate care, and to avoid duplication and omissions.

Already we are seeing comments from nurses and nurse managers that working together in local teams serving populations of 30-50,000 patients is leading to the development of better personal relationships between practice and community nurses, and greater levels of professional trust – so, for example, you can trust what someone else has written in the patient’s records. And this is better for patients who are cared for by smaller numbers of people, with a care co-ordinator, rather than being passed from one sector to another.

The traditional practice nurse does all the usual treatment room and QOF work but in the new environment that is changing – and she can become a care co-ordinator, or an educator, or a specialist clinician or a manager.

Working in a larger group also presents increased opportunities for education and study, and for those who are interested in it, opportunities for research.

Our practice nurses include one who is an emergency nurse practitioner (ENP), who leads a team which includes several other ENPs, paramedics and healthcare cassistants. She has developed a forum with nurses working in local minor injury and A&E departments, to run study afternoons, share information, and develop protocols that we can all use – rather than each practice developing their own.

REFERENCES

1. The Health Foundation. Health and social care funding explained. 2016 http://www.health.org.uk/health-and-social-care-funding-explained

2. NHS England (2014) Five Year Forward View https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf

3. NHS England South (2016), Sustainability and Transformation Plans https://www.england.nhs.uk/south/info-professional/stps/

4. NHS England, New Care Models. 2015 https://www.england.nhs.uk/ourwork/futurenhs/new-care-models/

5. NEW CARE MODELS: Vanguards - developing a blueprint for the future of NHS and Care Services. 2016

https://www.england.nhs.uk/wp-content/uploads/2015/11/new_care_models.pdf J

6. Encompass Multi- Specialty Community Provider (MCP) Value Proposition 2016 [online] www.encompass-mcp.co.uk

7. Colom. F et al: A randomized trial on the efficacy of group psychoeducation in the prophylaxis of recurrences in bipolar patients whose disease is in remission. Evid Based Ment Health. 2003 Nov;6(4):115 https://www.ncbi.nlm.nih.gov/pubmed/14585788