General practice: case studies of GP organisations working at scale to deliver access and continuity

As part of our "General practice on the brink" series, we describe what needs to be built into general practice reform. The case studies below illustrate different types of GP organisation, owned and managed in different ways, which demonstrate options for improving access while also maintaining continuity for patients who need it.

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Published: 17/05/2022

The case studies below illustrate different types of GP organisation, owned and managed in different ways, which demonstrate options for improving access while also maintaining continuity for patients who need it. 

They are not intended to illustrate perfection. Each of the case study organisations face recruitment challenges and they run out of appointments. Like practices across the country, they are trying to tackle inequalities in digital access and have to deal with patient frustrations. But they illustrate ways to organise services that balance access and continuity, and blend use of digital technology with face-to-face appointments.  

Their current service delivery models have evolved over many years. As we highlight in our final blog, policy-makers cannot expect these kinds of services to appear overnight and they will only stand a chance of replication if there is substantial investment in setting them up elsewhere. 

The case studies are:

AT Group Digital Hub

Location: Greater London

Registered population in London: 420,000 patients

Number of practices participating: Each digital hub serves a cluster of GP practices run by the AT Group with between 50-100,000 registered patients.

Digital access platform: Dr. iQ – developed by AT Medics’ technology arm (AT Tech) to support online consultations, information and self care advice, request medications, access test results and contact the GP practice.

Staff providing Hub services: One GP supporting a variable team of around seven allied health professionals (teams can include pharmacists, physicians associates and advanced nurse practitioners) supported by a Dr. iQ admin lead and four entry grade administrators.

Organisational model: Skill mixed team led by a GP responding 8am to 6:30pm to online consultations submitted through the Dr. iQ app. Staffing levels can be flexed to transfer a hub team member to a practice with very low capacity on a particular day.

Digital ‘appointment’ capacity: Up to 25 consultations per AHP per session. GPs deal with 10 consultations in addition to helping with triage and providing support and guidance. When all these consultation slots have been filled, Dr. iQ clinical pathways are switched off until the next day, although admin-related areas of the app and medication requests are still available. With efficient triaging and admin support, this is generally around 4pm.

Access to GP services for acute illness and on-the-day appointments: People who can use the Dr. iQ app submit an online consultation which is managed in the digital hub. 

Other patients can walk-in or telephone their own practice to book an appointment through the practice receptionists. Around 50% of consultations are requested online, and 50% booked by phone or in person.

AHPs in the digital hub can respond to an online consultation by messaging the patient; phoning the patient; booking a call back from a GP or booking a face-to-face appointment in their own practice. If continuity is needed and capacity allows, these appointments can be with the patient’s usual GP and longer appointments can be booked.

Practices linked to the digital hub hold embargoed appointments that can only be booked by Dr. iQ administrators, who have direct access to the medical record and booking system.

Continuity and ongoing care: Patients with ongoing or complex problems and no urgent symptoms who submit an online consultation can be booked in with their usual GP by the Dr. iQ admin team. GPs can also advise patients to request a follow-up via Dr. iQ appointment with them personally.

Links with community organisations: The digital hub administrators can act as care navigators, steering people with social and work related problems to local community and third sector organisations, supported by an in-house developed local directory of services.

For more information about the AT Group digital hubs, contact the Managing Director, Omar Din, on omardin@nhs.net

St Austell Health Care

Location: St Austell, Cornwall

Total registered population: 36,800 (mainly urban / suburban), five sites Including one rural

Number of practices participating: St Austell Health care formed as a single GP practice through a merger of three practices and further 10,000 failed practice in 2014. It also took on a two-year APMS contract to run a rural site with 5,000 mainly rural patients in September 2020. The practice forms a primary care network with the Mevagissey practice.

Total staff employed by the practice: 10 WTE GP partners, four salaried GPs, 14 practice nurses, two clinical pharmacists (one pharmacist partner), three advanced nurse practitioners (ANPs), three minor illness nurses, one paediatric nurse, two women’s health nurses, 17 health care assistants.

Total staff employed by the PCN: 2.5 WTE CPNs, four paramedics, three social prescribing link workers, one PA, one first contact physiotherapist, three pharmacists, two care coordinators.

Population characteristics: Deprivation: group 5 with a high prevalence of chronic disease.

Workforce model: 4,000 patients per full-time GP, working with an extensive clinically skill mixed force and strong emphasis on collaborative working with partner organisations across health & social care and the VSCE. Model of care developed with the NAPC Primary Care Home Programme.

Access to the practice: walk in or telephone requests to book an appointment, or contact the practice through an online consultation. Receptionists follow triage rules to allocate to acute or continuity service according to need rather than demand. Complex patients are, where possible, booked with their usual clinician.

Digital services used by the practice: e-consult for online consultations; AccuRx for messaging and some elements of long-term condition review and the NHS App for booking appointments, access to test results and medical records and requesting  medications. Currently moving to klinik for online access and AI triage to most appropriate clinical services. About to launch Omron for BP self-management and TeamsNet for back office/HR.

Access model for acute illness and on the day appointments: Acute and planned care access have been divided since 2014. The acute care hub is located in one of the five sites and provides urgent access for acute care 8am-8pm Monday to Friday.

The clinical team for the access clinics comprises, nurses, paramedics, first contact physiotherapist, mental health workers, paediatric nurse, pharmacists and physician assistants. Two ‘acute care’ GPs working in a room in the acute hub are available to support the clinical team when needed and see any patients from the duty doctor list who need a face-to-face appointment with a GP.

Continuity and ongoing care: GPs see their own continuity patients at their ‘base’ practice. Complex and chaotic individuals tend to turn up at on-the-day access clinic and, where possible, the reception team steer them back to continuity of care with their usual GP.

Working with patients: Patients involved in service co-design. Have an active PPG. Patients act as voluteers.  

Community links: the PCN employs three social prescribers with a particular focus on mental health and children and young people’s health. They are working on various proactive population health initiatives including with Ukrainian families and frequently attending patients. The social prescribers and clinicians work closely with community groups; schools; the Town Council; drug and alcohol rehab teams and mental health and community providers, to promote a culture of place-based care.

Quay Health Solutions

Location: North Southwark, London

Total population served by QHS: 200,000 patients

Quay Health Solutions (QHS) GP federation formed as a community interest company in 2011 to support its then 20 member GP practices. QHS provides extended access appointments to support all 14 current member practices deliver urgent appointments to the registered population of north Southwark.

Staffing model for QHS: Clinical services are provided a group of GPs, nurses, first contact physiotherapist and apprentice nurse associates. Some clinicians are employed by QHS and others are local GPs and nurses who undertake some clinical sessions in the Extended Primary Care Service (EPCS). Administrators undertake call and recall for preventive services such as smears, and immunisations, NHS Health checks and TB screening.

Population characteristics: QHS serves the neighbourhoods of Bermondsey, Rotherhithe, Borough and Walworth, with most patients living in wards in the top two deprivation deciles.

Access to acute care appointments: Appointments are booked through each patient’s usual practice, following triage by a clinician. Some appointments are ringfenced for 111. They are embargoed until 24 hours before the appointment time on weekdays and made available to 111 and out-of-hours services over the weekend. Each practice has a notional number of appointments related to it list size and will be contacted if it regularly overshoots its patient numbers. On busy days, appointments can be fully booked by mid-morning.

Links between QHS and member practices. All member practices and the Extended primary care hub use the EMIS medical record system. The EPCS has read and write access to each practice and consultation notes are saved into the patient’s medical record in their own practice. EPCS doctors can generate forms for blood tests, X-Rays and ECGs which are saved in the patient’s medical record in their own practice, but people are referred back to their practice if they need an ultrasound or other tests. Clinicians in the EPCS can contact a patient’s usual GP or home practice using EMIS ‘tasks’ messages, and GPs can alert QHS if they feel that EPCS doctors are ordering inappropriate tests.

Continuity and ongoing care: Patients are only booked into the EPCS following clinical triage by a clinician in their own practice. The service is set up to see people with minor acute illness so that their GP is freed up to see those with complex ongoing problems.

Additional QHS services:  QHS is open from 8am to 8pm every day of the year. In addition to the EPCS, they provide population health management and preventive services including smears, long-acting reversible contraception, immunisations, NHS Health checks and TB screening.

QHS provides additional clinical staff through the ‘ARRS’ scheme for north Southwark PCN delivering medication reviews and social prescribing, alongside two GP contracts – one for 6,000 patients and the other specialising in enhanced health care to people living in nursing and residential homes in Southwark. It also supports practices to employ newly qualified nurses and to develop the professions and leadership skills.

Links with the local community: Through the social prescribing service, QHS has strong links with many local community organisations including Bede House that specialises in support to people with learning disabilities. QHS is also working with Dementia UK to introduce an Admiral Nurse service for people, and their carers, living with dementia.

Foundry Healthcare

Location: Lewes, East Sussex

Total registered population: 28,200 across five sites spanning urban and rural communities.

Number of practices participating: Foundry Healthcare formed through a merger between three practices in Lewes in 2019. The practice forms a single primary care network.

Total staff employed by the practice: 16 GP partners, nine salaried GPs, four GP registrars, 10 practice nurses, two clinical pharmacists, one pharmacy technician, three first contact physiotherapists, one paramedic, 10 health care assistants, eight care coordinators, one social prescriber.

Total staff employed by the PCN: 92

Population characteristics: Deprivation: IMD decile 8 with <5% of non-caucasian registered patients. 72% local employment rate.

Workforce model: GPs do a mix of continuity sessions in their base practice and green (acute) clinic sessions in the community hospital, working with the practice paramedic and additional clinicians seconded from the adjacent urgent care centre run by the community trust. The green clinic is overseen by that day’s duty GPs. All GPs rotate through acute and continuity sessions although locums are concentrated in the acute clinic.

Access to the practice: Patients can walk in or telephone to book an appointment, or contact the practice through an online consultation.  

Digital services used by the practice: eConsult for online consultations; AccuRx for messaging / video consultations, accuRx and Ardens for long term condition digital reviews. The NHS App / Systmonline for booking appointments, access to test results and medical records and requesting medications along with Systmone ‘Text to Book’ for Chronic Disease Review appointment booking. HERE (https://hereweare.org.uk/) and Edenbridge (https://www.edenbridgehealthcare.com) for operational data. MS Teams for internal communication. Digital Primary Care for Workforce and Financial Management.

Access model for acute illness and on the day appointments: Patients are streamed using systematic triage created by clinical judgement identifying patients as green (generally well), amber (long-term conditions), and red (vulnerable or complex). Green patients where continuity is less important are directed to the green team collocated with an urgent treatment centre staffed by paramedics and GPs. On-the-day access for amber and red patients is directed to the usual GP or small practice team. Amber patient over flow is directed to the green site to manage capacity across the multi-site practice with red patients always being seen by their usual team.

Continuity and ongoing care: Labelling of patients improves multidisciplinary team working so patients see the right health professional at the right time. Proactive care with care coordinators is directed to the Red patients with more complex needs. Care for amber patients with long-term conditions  is coordinated by their usual GP supported by a multidisciplinary team including nurse specialists and pharmacists.

Community links: A team of care coordinators and social prescribers have created close links with local community and voluntary services and have developed a number of supportive projects including a dementia café, wellbeing garden and men’s shed.

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