Infrastructure, Intelligence, Interventions, Innovation and Incentives – leading us to Integration.

Organisation

Wokingham Primary Care Networks

What was the aim?

Practices across north, east and west Wokingham began working together in 2014, officially establishing a collection of three primary care networks (or neighbourhoods as they are known locally) in May 2017, collectively covering a total population of 165,000. Their aim was to join up patient care and reduce pressures across the system, whilst encouraging patient to consider self-care options in order to improve wellbeing across the locality.

Prior to beginning this initiative, patients often reported that services did not feel joined up, and that they had to tell their story to health professionals multiple times.

Alongside this, demand for primary care services was already at a high.  As an area with a high population of elderly people, many of whom had complex needs, and a growing population, demand on primary care was high.  A 25,000 rise in the local population? was expected by 2026 and the local GPs wanted to consider how to mitigate this.

As in many other areas of the country, recruitment was also an issue, not just for GPs but also for practice staff.  Practices were working in silos and there were local challenges about sharing staff across boundaries.

What was the solution?

In order to inspire engagement from patients and local stakeholders, an initial stakeholder event, which included patients and local partners, took place in 2014.  Similar events have continued to take place as the programme has developed.  Focused sessions with practices to help them understand the value of providing services at scale have also been held.

What were the results?

A multi-disciplinary team, which included nurses, community matrons, social workers, voluntary sector organisations, GPs, paramedics, elderly care consultants, mental health, community trust care coordinators and other relevant parties was established, to look at patients most likely to be admitted in to hospital.  By working together, the team have put processes in place to ensure patients do not have to repeat their stories multiple times and their care is joined up.

In addition, a paramedic home visiting service was set up, funded through the Five Year Forward View, to ensure patients in need of a home visit could urgently be seen by a paramedic rather than a GP. Home visits led by paramedics have increased the number of patients that can be managed at home and encouraged closer working and earlier involvement of social services, earlier intervention and community teams.

Next steps

An urgent care clinic has been set up in the west neighbourhood, staffed by a variety of clinicians including a paramedic, urgent care nurse, a physician associate and a pharmacist, with supervision from a GP.  The other two neighbourhoods in Wokingham are now developing their own similar local models which will be adapted to suit their local patient need.

A further project is also underway, focussing on the management of leg ulcers, as this is deemed to be an area which currently takes a great deal of clinician time. The project will require tissue viability nurses and potentially practice / district nurses and health care assistants running joint clinics in which patients would be able to see a health care professional and speak to fellow-patients about their issues and experiences.