The initiative was set-up to combat the frequency of GP call-outs – often multiple times daily, sometimes even for the same resident. It was the idea of GP Senior Partner Dr Simon Hambling. The team at Askham and two other local GP partners, Dr Elizabeth Mather and Dr Joyce Uzokwe, now hold weekly on-site meetings with lead nurses followed by visits to individual residents. The result has been a dramatic decrease in out-of-hours call-outs and a reduction in the pressure and usage of GP time.
Every Wednesday, GPs Dr Mather or Dr Uzokwe – both from Fenland Group Practice – along with Askham Quality Manager, Nikki Hobbs, meet individually with the lead nurse from each of Askham’s five specialist care homes. Meetings cover any concerns raised by nurses and care staff as well as ongoing issues identified by the GP. Thanks to the proactivity and preparedness of the Askham nurses, together with the integration with the GP computer system, referral letters to specialists, blood test requests, prescription writing and a general update on resident well-being can all be completed on-site. Meetings are followed by one-to-one visits by the GP to any resident in need of attention.
“Before each meeting, we co-ordinate information on each of the residents we would like the GP to see that day. Then, we fax it to the GP in advance so they can be fully prepared – it’s simple but incredibly effective,” explains Nikki. “Each nurse gets time to discuss residents as well as get things like referrals and prescriptions sorted. Observations including blood pressure and temperature are conducted by our nurses, before the GP arrives. The amount of time and resource it saves is staggering. The GP does resident’s visits before and after the meeting. The best thing about this is, if someone’s condition was to change in the interim, the GP already knows the resident well and is comfortable coming out in more urgent situations and means some follow-up work can be undertaken by telephone.”
The success of the scheme is clearly measurable for all concerned with reduced out-of-hours GP call-outs for residents, reduced ambulance call-outs, reduced hospital admissions, and, as Dr Mather explains, an increase in GP productivity:
“It’s a very efficient way of providing comprehensive patient-centred care and one that I firmly believe should be utilised nationwide in the future. Myself and my colleague, Dr Uzokwe, are able to plan and prepare for regular visits, meaning that patients receive continuity of care and the streamlined service is more work-efficient for the practice. By reducing care home call-outs on a daily basis we can ensure there is more time for our other patients so it benefits the wider community.”
Dr Mather continued: “I’m aware that similar schemes are evolving across the UK, particularly Pharmacist and Lead Nurse liaison; but I think what we have achieved is more powerful. This is because, over an 18-month period, we have built very strong doctor-nurse relationships. Trust and mutual support emerge as key factors enhancing individualised patient care. ”