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Good Practice: Reconfiguring services - Community services work with GPs

Hampshire Community Health Care wants a better fit between services and practices.

Dr Hughes: 'There are savings to be made by sharing back-office functions, such as HR and practice management'
Dr Hughes: 'There are savings to be made by sharing back-office functions, such as HR and practice management'

An integrated care system in Hampshire means GPs and community staff work more closely together across health and social care to provide better care for patients.

Hampshire Community Health Care (HCHC), the provider arm of PCT, NHS Hampshire has reconfigured its services to be more streamlined. The aim is to reverse the trend of patients defaulting to hospital care by introducing new ways of working.

These include community-based 'virtual wards', managed by GPs and community matrons, and the availability of GP beds in community hospitals where general practice is responsible for the care.

The community workforce is in the process of being re-aligned to practice-based commissioning boundaries and general practices are being encouraged to form federations.

Sue Harriman, director of clinical delivery and excellence at HCHC, says a federation means family doctors can have more influence over local services while still making the closer relationship economically viable.

'Every GP practice may want their own health visitor and (district nurse) sister but that model is cost-prohibitive. In a federation, however, that model works really well,' she says.

Work together closely
GP Dr Barbara Rushton is clinical lead for a federation of 15 practices, East Hampshire Alliance, which has been running for nearly a year.

She says general practice and community teams work together much more closely than they did before.

'A good illustration is end-of-life care where lots of patients used to get scooped up during the night and taken to hospital. Now we have a very skilful set-up with community nurses, GPs and other services such as Macmillan nurses to keep those patients at home,' says Dr Rushton.

HCHC medical director Dr John Hughes says that forward-thinking practices see benefits for themselves as well as patients in forming a federation. There are savings to be made by sharing back office functions, such as HR, practice management and reception.

Dr Hughes points out that there is also a sense of safety in numbers: 'A federation gives them some protection against the aggressive competition from private providers.'

The change initiative in Hampshire began three years ago when a new executive team came into being. HCHC chief executive (designate) Katrina Percy wants to see the same outcome-oriented approach in community healthcare as there is in secondary care.

Her background in the acute sector means she knows what focusing on productivity is like. HCHC analysis showed that community care did not have it.

'We found there was a lot of overlap between different services. Community staff were seeing end-of-life patients, leg ulcers and long-term conditions so they were overlapping with practice nurses and social care. There was even overlap between our own team, such as district nurses and rapid response staff,' says Ms Percy.

Integrated care system
Yet in spite of the various teams, patients would still be admitted into hospital when it was not in their best interest.

So HCHC came up with the model of an integrated care system.

The system comprises local primary and community care services, plus the relevant components of acute elderly, mental health and social care.

Ms Percy says that, in a nutshell, the model saves money, avoids duplication of effort and improves patient care.

The five-year aim is to achieve efficiency gains of about 30 per cent by increasing productivity, reducing costs and removing duplication in community services. Ms Percy also wants to reduce elderly occupied bed days in acute hospitals by up to 40 per cent.

Even though Dr Rushton says that integrated care 'has to be the way forward', she admits that it has not been easy to work in new ways.

'The difficulty is that GPs are suspicious and so are community staff who feel their jobs are on the line. We know we have to make savings so people think that means cuts to jobs,' she says. However Ms Percy insists there will be no redundancies in front line posts or cuts to service.

But it is not only grassroots practitioners who are wary of the changes. NHS Hampshire announced in January 2010 that it would not support HCHC's plan to become a foundation trust.

Then, in March, it said it wanted HCHC to merge with the mental health trust. Negotiations have been taking place with HCHC and the mental health trust which may end with HCHC being acquired by the other body.

Ms Percy says that the chief executive of the mental health trust is supportive of the new ways of working. But she admits that a merger could jeopardise the changes.

'The danger is that we'll be talking about the merger and not advancing the integrated care work.

It could be a distraction,' she says.

Assuming the plans go ahead, the ultimate aim is that the integrated care system would run itself. The practice federations will be part of a partnership board, which includes other stakeholders such as social care.

Commissioners would set the outcomes but the boards would be given the freedom - organisationally and budgetary - to decide how to meet them.

'There's a big opportunity here,' says Ms Percy.

She just hopes it won't be squandered.

Changes to services

The changes that Hampshire Community Health Care (HCHC) is implementing include:

  • Community-based virtual ward to ensure the most vulnerable patients are given extra support at home to avoid hospital admission.
  • Closer working between community nurses and general practice.
  • Clinics rather than home visits for some of the bread-and-butter work of community staff, such as looking after patients with leg ulcers.
  • GP beds in community hospitals where general practice is responsible for the care.
  • Clinics at a community hospital staffed by GPSIs and a consultant geriatrician for advanced diagnostics to avoid acute admissions.

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