Leading change

The newly appointed Practice Matron at Consett Medical Practice introduced and led an enhanced approach to supporting residents in care homes registered with the Practice. This replaced a more re-active service being offered by the GPs. The Practice Matron led a programme of work to address and change this, strengthening working relationships with the residents and care home staff. The changes led to the matron becoming the first point of contact for the care homes, delivering a responsive and proactive care approach. Staff are now more skilled in supporting residents to stay within the home and not be admitted to hospital and GPs are spending less time home visiting. This has improved patient outcomes, quality of care, partnership working, and has led to a more effective use of resources.

Where to look

Consett Medical Practice had 239 registered patients residing in one of eight care or nursing homes and one supported living residence. A reactive service had developed where care homes would routinely request GP home visits for residents if they were ill and required assessment and intervention. Before this change, there had been an unwarranted variation in nurse led services for care home residents. The service model being delivered locally across County Durham and Darlington NHS Foundation Trust (CDDFT) had historically consisted of community matrons each assigned to care homes but there was no general practice based provision which provided residents with access to practice nurses.

Residents were in need of a more consistent structured approach that was not only responsive but proactive, with visits for comprehensive assessment and care planning tailored to the individual NHS England (2016).

There was potential to provide practice based care but this would require closer working relationships with the residential homes. This would improve patient care, as well as provide an opportunity to free up GP time by having nurse led support.

What to change

Before the change, the GPs were routinely visiting and providing care to residents upon request. The demand on GP time meant there was little opportunity to provide a more proactive approach, such as upskilling staff to support residents to stay at home and avoid hospital admission and having greater focus on promoting health.

Consett Medical Practice identified the opportunities change could bring. They employed a Practice Matron who had previous experience as a community matron in delivering packages of holistic support to residential care homes and those housebound. The Practice Matron identified the opportunity for the practice to offer a more bespoke version and began by approaching the residential care homes to begin forging the close working relationships which would lead to an offer of care and support that would be the building blocks of change.

How to change

The changes focused on the Practice Matron providing:

• The first point of contact for both GPs and staff/managers in relation to residents registered with Consett Medical Practice, including reviewing all requests for medical support;
• Daily visits to residents, providing a responsive and proactive approach, like a ward round within a hospital, reducing demand for reactive medical support;
• Clarity of the service offer being provided by the Practice Matron and parameters for requesting GP support;
• Medication reviews and supporting care planning;
• Reviews and undertaking of advanced care planning such as Do Not Resuscitate orders;
• Ensuring robust mobile working with a phone and a laptop. The laptop enabled timely patient record reviews, GP instant messaging for advice and support, medication reviews, prescribing and electronic referral to pharmacies for instant medication prescriptions; and,
• Access to the service Monday to Friday between 09:00 hrs – 17:00 hrs including a telephone support system over the same period.

The Practice Matron also supported:

• Training and education with the residential home staff, providing an opportunity to empower staff, develop their skills further in order that they can support their residents to stay healthy and potentially lower the number of hospital admissions;
• Closer working relationships with registered nurses from nursing homes, offering leadership and guidance and supporting them in their professional practice;
• Consistency and quality of care across the residences; and,
• Working with individuals, families and the community to equip them to make informed choices and develop an understanding of how they can be empowered to manage their own health.

Adding value

Over a six-month period, the impact of the Practice Matron was measured which found:

Better outcomes

• A 63% increase in visits to patients suggesting previously unmet need;
• 30% more medication reviews when compared to same period before change;
• Care Home staff reported improved outcomes for residents;
• GP visits reduced by 48% as effective care and support is provided by the Matron; and,
• Feedback from GP of more timely and appropriate reviews of ‘Do not attempt CPR’ forms as well as achieving more frailty reviews.

Better experience

The Practice Matron has received very positive feedback from GPs, Commissioners and residents:

• ‘is patient and understanding, a very pleasant visit’;
• ‘very responsive, always giving good practical advice…our service would be at a loss without her expertise’;
• ‘Residents feel at ease and have become familiar with the consistent care provided by the Matron…staff have benefited by having a Practice Matron in the home regularly, this has given them clinical support on a day to day basis…. staff also feel confident in the advice given by the Practice Matron and recognise that she can pick up on changes in residents promptly’;
• Waiting time for GP care has significantly reduced; and,
• Continuity of care has improved residents’ experience.

Better use of resources

• A more cost-effective use of GP time as the nurse is available to support the initial contact with residential facilities and manage most of concerns identified. A practice GP described the impact as ‘dramatically reducing the work load of home visit requests for the GPs’;
• The Practice now has the right staff in the right place at the right time; and,
• The Practice has increased the visibility of nursing leadership and input in prevention.

Challenges and lessons learnt for implementation

This programme of work has identified:

• Nurse leadership can offer an alternative, high-quality service to that of GPs;
• Effective support from a nurse can change residential facilities’ culture and empower their staff to understand the needs of their residents;
• Programmes such as this may be challenged by resistance, perseverance will create the change for success;
• Invest in partners and support them to see the benefits with clear outcomes and benefits of change;
• This programme is cost effective as nursing leadership can take some of the burden from GP time;
• Good relationship building is important to ensure that all the partners are on board with the changes;
• Small ideas can make a big change, this small idea has had a big impact on the GP practice and on the quality of care within the residential facilities; and,
• The service is now mainstreamed. All residential facilities call the Practice Matron directly rather than the GPs.

Find out more

For more information contact:

• Sharon Haggerty, Deputy Director of Nursing, Nursing and Quality, NHS England (Cumbria & North East), sharon.haggerty@nhs.net
• Deborah Donnelly, Practice Matron, Consett Medical Practice, deborahdonnelly@nhs.net