East Kent is a good place to visit for an insight into the new world of general practice.
Whitstable Medical Practice has worked on large scale general practice and integrated healthcare for many years, believing it will provide better healthcare for its 35,000 patients.
For Dr John Ribchester, senior and executive partner at Whitstable Medical Practice, a pivotal moment was the opening of its new Estuary View Medical Centre in 2010.
‘We made it three and a half times the size we needed for the GPs,’ he says.
That health centre, one of three the practice works from, now houses not only GPs but also a minor injury unit, consultant-run outpatient sessions, diagnostic and screening services, a community pharmacy and ambulance response base. It provides care to a natural community of around 40,000 patients and has delivered savings of £1.6m or 3.5% of its budget.
Dr Ribchester argues that large scale general practice need not lead to the loss of personal care. For example, Whitstable GPs have always maintained their personal lists. He adds: ‘It feels good from the patient’s point of view and from the GP’s point of view. You know the buck stops with you.’
MCP vanguard site
Whistable Medical Practice’s work merited a mention in the government’s Five Year Forward View published in 2014 which sets out a strategy of integrated working for the NHS.
Whitstable was selected as one of the vanguards for that strategy’s new models of care programme as a multispecialty community provider (MCP). MCPs are to be made up of groups of practices covering a minimum registered list size of 30,000 and offering a wider range of care.
The east Kent MCP covers 16 practices with 170,000 patients. Dr Ribchester, who is also clinical lead and chair of the Encompass MCP Vanguard, says the MCP’s ambitions are to replicate the work taking place in Estuary View at other hubs. The group is focusing its activity on four different ‘modules’, with much of the work already in place at Estuary View.
The first of these is a long term conditions module aimed at bringing the clinician to the patient. So for example in cardiology, a GP with a special interest in cardiology triages all referrals and both the secondary care cardiology consultant and the tertiary cardiologist see patients at Estuary View. Patients also have access to heart failure, arrhythmia and rehabilitation nurses. This has delivered a 30% saving on the practice’s previous cardiology spending.
The second module covers urgent care. The Estuary View hub houses a level three minor injury unit which is open 8am to 8pm seven days a week. It has X-ray available seven days a week, ultrasound six days a week, as well a fracture clinic and DVT diagnosis and treatment facilities.
Dr Ribchester says 80% of those who attend never go to hospital. ‘It genuinely is a community project.’
The MCP also plans to set up 8am to 8pm general practice seven days a week. The Estuary View hub is the base for paramedic practitioners who now undertake 20% of in-hours GP visits using iPads with read and write access to the GP record.
Dr Ribchester says about two-thirds of those visits are completed solely by the paramedics. ‘There is continuity of care and huge amounts of patient satisfaction,’ says Dr Ribchester. ‘The paramedics are also becoming the friend of care homes, teaching them first aid and increasing the skill and confidence levels to reduce transport into hospital.’
Elective care and diagnostics
The third module covers elective care and diagnostic services. More than 20 consultants work from the outpatient suite at Estuary View and have access to everything they need to complete episodes of care.
The Estuary View site also provides a day surgery service carrying out cataract operations as well as dermatological and carpal tunnel surgery and a steroid injection service. Therapy services include physiotherapy, a hearing aid clinic and acupuncture. The site also runs a range of clinics provided by GPSIs and a first year project is to build on the GPSIs.
The MCP is also developing a ‘social prescribing’ service which will provide a single point of access telephone service for 144 voluntary organisations which Dr Ribchester hopes will lead to reduced mental health referrals and reduced isolation.
Another project is developing integrated expanded nursing teams which will bring together district nurses, social care workers and mental health nurses in the same room and using the same record with a care co-ordinator.
The most ambitious project for the MCP, and the fourth module of its integrated care plan, is on enhanced rehabilitation and intermediate care. The MCP is driving the development of what Dr Ribchester describes as a ‘health and social care network or village’ which he hopes will be operational at the end of 2017.
This involves the building of a new community hospital , a teaching nursing home, sheltered housing and a day centre, all on the same site. The plan is that the village will eventually lead to downsizing of the acute hospital.
For Dr Ribchester the key to success is good relationships and he says that everybody must be involved. In east Kent this means a strong role for patients plus a vanguard board which includes representatives from general practice, every trust, the CCG, hospice movement and social care.
He adds: ‘If one organisation has a great idea unless that idea is integrated with everybody else it doesn’t go very far. For health services and social services to survive the attitude has to be your problem is my problem.’
For Dr Ribchester there are prizes of taking that approach for patients, the health economy and GPs.