Note: Some sections of this case study refer to clinical commissioning groups (CCGs). On 1st July 2022, integrated care systems (ICSs) took over statutory commissioning responsibilities in England, and CCGs were closed down. You can learn more about integrated care systems (ICSs) here.
Case study summary
As one of the first CCG areas to see all GP practices unite to form a federation (the Richmond General Practice Alliance or RGPA), Richmond-upon-Thames in London has led the way in integrating their ways of working to transform and improve access to general practice. The federation incorporates all 28 general practices and all 215,000 residents of Richmond-upon-Thames.
What was the challenge?
As part of Wave 2 Prime Minister’s Challenge Fund, the RGPA was tasked with offering 8am to 8pm 7 day access to core general practice, to localities of approximately 50 000 patients. They were tasked with running a service that could deliver all of core general practice in Hub settings at the same level of quality as in the home practices. They were also tasked with delivering interoperable GP IT working across both EMIS and Vision systems, and delivering a patient-direction app.
Richmond faced a series of technical and logistical obstacles to transforming their service provision. Foremost amongst these was the challenge of delivering practical interoperability: real-time data flows to and from the different clinical systems in use across the practices. There was also a need to get practices in each locality to take ownership of, and responsibility for, a service delivered from a remote site. There was a need to integrate separate clinical and IT systems, and reform ways of working without impacting the day to day running of the practices. This presented a significant implementation challenge.
What were the opportunities?
By working together at CCG and locality scale, Richmond general practices realised they were able to deliver a service that could offer something for everyone: better access for patients, reduced workload and greater resilience for practices, and an improved primary care offering for the CCG.
They also realised that this would open up the opportunity to deliver an extended range of better, safer, faster and more cost-efficient services, with a more consistent, joined-up approach for patients.
Through partnership working with other community-based organisations (such as community services, charitable and third sector organisations, mental health providers, and patient groups) working at federation and locality scale enabled them to explore new and innovative ways of delivering wider primary and community care (both in core and extended hours), and also look at ways of delivering healthcare that has previously been delivered in a secondary care setting
What did they do?
- Extended the availability of general practice appointments through the establishment of community hubs. Originally there were four Hubs, which has been reduced to two as of 2017. Each now serves a locality of approximately 105,000 patients offering both urgent and non-urgent care appointments. The Hubs offer the full range of extended general practice services, such as chronic disease management, contraceptive services and acute care management. In the first year of activity, the Hubs saw approximately 45,000 patients. Feedback from patients was excellent, particularly regarding the reduced waiting times, which were made possible through increased capacity. The majority of the GPs working in the Hubs were either locums or portfolio/part-time GPs who were returning to work, attracted by the flexible working structure of delivering general practice within Hubs.
- Integrated IT systems. Working closely with software houses EMIS and Vision, the federation was able to ensure their systems worked in real-time when reading and updating patient records: they created and implemented the first real-time truly interoperable remotely accessible GP record. This meant patients could use the Hub service and the GP was able to have full access to their records; not just to read, but also to write and update with clinical information. This helped improve the efficiency and effectiveness of the hubs and the overall patient experience because the Hub GP had full access to the patient’s record and was therefore able to deliver the full range of care. The GP was also able to add to and update the record so that the patient’s own GP was immediately able to share necessary updates with the patient’s home practice.
- Worked closely with the local authority and other partners. To implement the hubs, the federation had regular one-to-one meetings with partner and stakeholder organisations (including patient groups, the CCG, community services, charitable and third sector, local councillors and politicians, and the local authority) to identify and understand important considerations for integrating their services. They worked hard at communications to maximise engagement and help to identify problems before they became an issue. These meetings were particularly helpful in discovering infrastructure roadblocks, such as practices that were running legacy IT systems that required new cable installations to successfully connect the area’s programmes.
- Engaged the local community to ensure patients were confident in the new services. An extensive programme of patient liaison meetings was conducted to build the programme around patient requirements, which led to greater understanding of their needs and the development of an app to direct patients to the most appropriate service first time.
What outcomes were achieved?
Establishing a federation and working more closely with providers in both primary and secondary care meant Richmond general practices were able to join up their services, provide closer-to-home care through the two hubs and reduce the burden on the broader system due to the additional capacity given by the hubs. The community hubs have been highly successful; with utilisation rates amongst the highest in London, at around 85%.
“The Improving Access to General Practice initiative has energised and boosted our integration programme; helping us to provide better services for the people of Richmond. Operating at scale has proven to be a crucial way for general practice to evolve and thrive” Darren Tymens, Chair, Richmond GP Alliance.
What are the key messages to take away?
For those looking to implement similar initiatives, there are two key learnings:
- Relationships within the primary care community are vital. Richmond GPs have strong partnerships with patient groups, pharmacists and the charity sector, which has created an environment of collaborative working. Through this network, the results achieved were best for all and empowering for different organisations to continue working together on new projects.
- Working with experienced software developers allows for a smooth IT integration process. Connecting 28 practice systems together without disrupting existing services was complex, but by collaborating with expert tech providers, GPs were able to integrate their records systems; improving both patient safety and experience, two key aspects of high quality care.