We’ve been using the primary care home (PCH) model in Luton to work collaboratively in the best interests of two specific patient groups – older people with multiple medications and those with type 2 diabetes.
A total of nine practices in two GP clusters joined forces with the local community provider – Cambridgeshire Community Services – to design and deliver services tailored around these two vulnerable target groups.
As is the case in most areas, we’re struggling in Luton to handle an ever-increasing demand for urgent care. The need to avoid hospital admissions through health education, by promoting the self-management of health and by collaborative working, has become incredibly important.
I and my fellow GPs in the Medics United cluster were particularly concerned about the increased use of medications among elderly people and the adverse outcomes – such as falls and hospital admissions – associated with polypharmacy.
Due to work pressures, it was difficult for us to find sufficient time to conduct the kind of medication reviews that, in an ideal world, we’d like to see being undertaken on behalf of all patients using several different prescription drugs at the same time.
With funding from the PCH programme, we worked with community services to test a new pathway designed to improve the care for patients with polypharmacy.
We appointed a clinical pharmacist for a three-month pilot scheme. The pharmacist worked as a member of our team, visiting surgeries and housebound patients, explaining and reviewing their medication in a one-hour consultation.
We focused on patients over 75 years, taking 10 or more medications. The aims were to identify medications that could be stopped or started, support and improve patient compliance with taking their medicines correctly, identify any prescribing or dispensing errors and avoid adverse drug reactions and hospital admissions.
Reduction in GP appointments
Early analysis has shown there was a significant drop in the number of GP appointments in the six months following the pilot. There were 892 GP appointments in the 12 months before the review, compared with 311 in the six months after it. While it’s difficult to attribute this reduction solely to the medication review, it does warrant further analysis to see if this change continues.
Expected benefits include a reduced and simplified medication regime for patients and fewer falls and hospital admissions. The savings to be had from stopping unnecessary medications are estimated to be more than £3,000 a year. These savings could be much more if these reviews were undertaken with other patient groups.
During the process, I’ve learned a lot about how clinical pharmacists do medications reviews and, I’m embarrassed to say, I hadn’t previously appreciated the full extent of their knowledge and skill. The pilot has made us realise the clinical pharmacist role could be expanded to include undertaking health checks, monitoring long-term conditions and being part of our multidisciplinary teams.
As a result of the pilot, we’ve now applied for funding to appoint pharmacists for our two GP clusters in Luton and are waiting on a decision from NHS England.
We have a high prevalence of diabetes in Luton and many of my primary care colleagues were concerned about patients not fully understanding their condition.
The Kingsway cluster of seven practices targeted patients who were struggling to self-manage their condition. One-hour consultation appointments with our community diabetes team were offered to these patients, giving them the opportunity to discuss how they had been managing their condition, any concerns or queries and what their recent medical results revealed. A plan was drawn up including how to access support and activities available in their area.
The pilot showed structured education really does work and substantial changes can be made quickly. Patient satisfaction was high and motivation levels to manage their own condition increased. If this could be maintained, the burden on provider services would reduce while health outcomes would improve.
The successes of both pilots, and lessons learned from them, have given me confidence that the PCH model does work in terms of both reducing the workload of GPs while at the same time improving the quality of the care we provide.
We're now looking at ways of building on this new collaborative style of working to improve services for other groups of patients, and there’s a real sense of excitement about it here in Luton.
If we can show a particular project works on a small scale within a primary care home, then it can be rolled out across the whole Sustainability and Transformation Partnership (STP). In terms of being part of an accountable care system, it’s still early days but in my view this kind of system – with providers and commissioners working together to meet targets – is an absolute necessity for the STPs to work.
Dr Manraj Barhey has been a GP at the Woodlands Avenue surgery in Luton since 1995 and is a former Chair of Luton Clinical Commissioning Group. The Luton Primary Care Cluster was among 15 rapid test sites chosen to pilot the primary care home model in December 2015.
Please note that views expressed in guest blogs on our website are the authors' own and do not necessarily reflect the views of the Nuffield Trust.
Barhey, M (2017) "Primary care home expands the role of clinical pharmacists" Nuffield Trust Comment www.nuffieldtrust.org.uk/news-item/primary-care-home-expands-the-role-of-clinical-pharmacists