'Changing Care' Articles

There’s no doubt the pandemic sharpened our appreciation of the NHS and the incredible efforts of its many practitioners to keep us safe and well.

As populations age and treatments become more complex, our GP services have come under pressure like never before and consequently they’re having to adapt to cope.

Groups of GP practices now work in clusters called Primary Care Networks (PCN). The eight PCNs in North Cumbia work closely with community, mental health, social care, pharmacy, hospital and voluntary services. They build on existing services to enable provision of proactive, personalised and more integrated health and social care for people.

PCNs typically serve communities of between 30,000 to 50,000 people. That’s small enough to provide the personal care patients value, but large enough to have impact and economies of scale through better collaboration.

In addition, PCNs can now directly appoint health and care staff to complement the traditional general practice team including clinical pharmacists, paramedics, occupational therapists, physiotherapists, mental health workers, care co-ordinators and social prescribers.

When a patient calls their GP practice it means they may be directed to other specialists who can give the most appropriate help.

Dr Robert Westgate is a GP in Carlisle and Chair of North Cumbria’s Primary Care Networks.

He said: “There are huge demands on primary care now – in my GP practice in Carlie we receive close on 4,000 calls a week, around 15% above pre-Covid levels. Alongside this increase in demand, we are seeing some patients with very complex problems that need expert medical support, and a reducing number of GPs.

“Over the last couple of years, we have been growing our primary care workforce, with new roles bringing different expertise into our practices to help our patients.

“When our reception team ask for more information, it is because they are trained to help patients get the support that will help them most effectively and appropriately – sometimes signposting to other services. This allows us to best match the needs of our patients to the skills of our team to deliver the right care.”

The national Additional Roles Reimbursement Scheme (ARRS) aims to build the alternative teams to begin addressing the workforce shortage in general practice. It is forecasted to create 26,000 new roles in primary care by 2024.

Practices across North Cumbria, from Copeland, up the West Coast and across to Keswick, Carlisle and Eden, are using these new roles in different ways to add to their traditional services.

Dr Richard Massey, Caldbeck Surgery GP and Clinical Director for Keswick and Solway Primary Care Network, added: “It’s natural that when people ring us with a concern they may want to be seen by a GP, because that has been the traditional route. But the GP may not always be the most appropriate person to help.

“Patients may benefit from seeing one of our clinical pharmacists, a primary care mental health worker or first contact physiotherapist.

“The great benefit is that we can refer people to a wider range of specialist help. We aim to ensure that patients receive support from the right specialist.”

Hayley and Rio are well practised in putting themselves in the shoes of others. It’s a necessary skill when you’re part of a busy receptionists’ team tasked with being the first face or voice that ill or worried patients are met with when seeking treatment.

Hayley Pearson is the senior receptionist for the James Street Group Practice in Workington, and a retail background has left her with few illusions of how demanding the public can be.

She said: “You’ve got to try and think of it from other people’s point of view. I know there’s no need for being rude, but sometimes they’re frustrated by the time they get through on the phone and frustrated that they’re not well and you’ve just got to try keep that in mind.

“When you ask them why they want an appointment that can just tip them over.

“But you’re doing it for their own good, and you need that information. There can be some quite difficult conversations. It comes down to experience, you just learn to handle it.”

Hayley, receptionist Rio Collins and the 20-plus members of the reception team have a vital role in getting people to the right appointment.

Rio said: “We ask what sort of symptoms they’re having because we have lots of different appointments and experts and people often don’t know what they need.

“People will often say it’s private when you ask what’s wrong and many times that can be because it’s a mental health issue. We have a mental health practitioner who is the better person to see because that’s where her expertise lies.”

Hayley adds: “People want to see their GP when they’ve got something like back pain. But the doctor is likely going to refer them to the MSK (musculoskeletal) clinic and that could be up to a 15 week wait for a referral that we could have offered that day.

“People often mistakenly think we’re fobbing them off with someone other than a GP, but we’re not. A GP is not always the best person for someone to see. The patient is actually adding time to how long they’ll have to wait for the right treatment.”

Rio said: “We try and coax them along. If you say to people you need to know what’s wrong so we know where to put them, then sometimes they will tell you.

“You’ve got to think it’s not personal on you, it’s just the situation. But sometimes it’s hard. We eat a lot of sweets!

“We get criticised on Facebook, sworn at down the phone.

“You do also get times where it is very fulfilling. You know that you are helping people. And all the lovely people that come in, they make it worthwhile.”

Hayley added: “If you can speak to one person who’s an absolute sweetheart it just makes those 20 difficult conversations more than worth it. It really does. You do feel like you’ve made a difference.

“That one person is getting something out of that, that’s all we can ask really.”

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The five surgeries in Workington work together as a Primary Care Network, which is one of the eight Primary Care Networks providing care for our population across North Cumbria.

Practices offer a variety of face-to-face, online and telephone appointments. All practices triage over the phone which means patients can be prioritised and directed to the most appropriate health care professional.

Reception teams do not make clinical decisions but are trained to help patients get the right service.

Julie Dawson recalls when there were just four practice nurses in her team. That’s multiplied to 28 now, part of a new wave of highly trained healthcare professionals needed to tackle growing demand.

Julie is Nurse Team Lead at Carlisle Healthcare. As well as her management role she also has a speciality in diabetes. And few things demonstrate the challenges faced by the NHS more graphically than the explosion of people now requiring help to manage that condition.

In a primary care network covering some 37,000 people, around 2,000 have diabetes, with a further 1,000 at risk of developing the condition. It’s little wonder the healthcare workforce has had to expand to meet the issues faced.

Julie explains: “Years ago we had a diabetic GP lead in the practice and everything went through him.

“As the numbers increased, we all needed to upskill to a point where all our long term condition clinics are now nurse-led.”

Lifestyle factors have played a huge part in the increase in type 2 diabetes. It used to be predominantly associated with the ageing population, but what Julie and her team are seeing is people developing the condition in their 30s, 20s and even teenage years. The growth in demand means a changing focus.

Julie said: “We do encourage patient education and self-care. When we first started this process, many people weren’t keen. It was like, ‘you’re the clinician, you tell me what I should do’.

“But we know that people make their own choices and do what’s important for them, and typically this isn’t what they are ‘told to do’. We have spent many years developing a care and support planning approach, working with people to identify their goals and actions and supporting them in their positive behaviour change.

“Now when people come to see us they may have already identified a plan to improve their health and reduce their future risk of complications. This approach has transformed how we work, and allowed us to focus more on the person, rather than the disease.

“Our biggest challenge is working with people who are not motivated to change.”

Diabetes is far from the only long-term condition affecting large numbers of the community. Heart problems, high blood pressure, respiratory conditions, strokes and kidney disease are also significant. Clinics for long term conditions at Carlisle Healthcare and across North Cumbria are busy places.

Sarah Sewell was a nurse who wanted to be able to do more to help the patients she was seeing. After three years of further study and training she is one of a growing number of Advanced Clinical Practitioners (ACP).

Sarah said: “It’s about bridging the gap because there are not enough doctors around. A lot of things can be managed by us, we can diagnose, treat and prescribe and we can do the ongoing referrals for further tests. We carry our own caseload of patients.

“A lot of us were nurses first and we don’t lose that nurse within us, but it’s about us extending the roles so we can give the right care to the right people at the right time. That frees up the GP’s time to look at more complex conditions.

“It was sometimes frustrating to be a nurse and you could see there was a problem, and you were constrained by ‘well that’s where my role ends’. Now there are options to go on and extend your skills.”

Some ACPs have specialist roles such as running well woman clinics, HRT, respiratory issues or paediatrics, as well as seeing the full range of illness and poor health.

Sarah said: “We see people from cradle to grave, at every stage in their life.

“Nine out of 10 people are more than happy to see us. For younger patients we’ve always been around in the background but for older generations this is new and different from where we used to be.

“We all want the same thing - for people to get good quality care. That’s not always easy, we are constrained by time, money, pressure and lots of other things. It is about us all working together.”

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Are the changes to care arrangements in GP surgeries getting through to the public?

Julie Dawson said: “Patients realise that we have a highly trained nursing team. But you do get people saying, ‘I want to see my own GP’, but the message is getting through. We are working differently, both out of necessity, and also to improve quality.

“I don’t think there would ever be enough staff to cover demand. You could put in another 100 appointments, and they’d all get snaffled up. There are big expectations out there.”

“I like to think that people get better care now because we are working more collaboratively with patients. I think our main challenge is increasing workload, and the rising numbers of people with long term conditions.”

“We look at things that might improve your health and wellbeing that aren’t found in a medication.”

Rachel Murdie has a short explanation when asked to describe how her role as a social prescriber helps people.

Social prescribing is increasing within the NHS as the service looks to move demands away from a traditional, doctor-led service and look more holistically at helping people stay fit and healthy.

Rachel, who works for Carlisle Healthcare, one of eight Primary Care Networks (PCN) in North Cumbria, explains further.

“We help people look at their wider health and wellbeing, not just their clinical needs. There might be something medical going on, but there might be other things feeding into that as well.

“We have time with them to explore what their needs might be and then try and link them in with community support.”

Those issues are varied. From housing and financial problems to relationships and low-level mental health issues.

Rachel estimates up to 70% of those she sees are affected by social isolation and loneliness, sometimes caused by bereavement and loss, and made worse since the pandemic.

She said: “A lot of lonely people have lost their way, or they’ve been through a life stage that leaves them thinking ‘I don’t really know who I am any more’. Or sometimes they’ve got a long-term condition. We can’t cure that, but what we can do is help them live well with that condition.

“We also work closely with groups like Age UK and Citizens Advice, which is really important with the cost of living crisis.”

Rachel’s colleagues describe her as the link between healthcare and the community third sector.

She said: “My privilege is time, which is what the clinicians don’t have. For some people it’s just signposting to what’s available.

“And when you’re feeling run down you are more susceptible to illness, so sometimes it’s just keeping people on an even keel.”

Different surgeries will use social prescribers and other alternative resources in slightly differently ways.

While Rachel currently only works with over 18s, at Workington’s James Street Group practice they’re also helping young children and families.

Social prescriber Kelly Holliday said: “We’ve got families who have felt isolated, children that don’t really want to go out. So we’ve got groups set up now for the children and we can work with schools as well.

“We have noticed a huge rise in family cases since lockdown, so we do try and make a difference, supporting everyone really.

“It was a bit of a slow burn at the beginning with 25 referrals in the first month, then it snowballed. We are getting 100 referrals a month now. We get referrals every day for people suffering with low level mental health and that is what social prescribing is there for.”

Valued service

Assistance can sometimes be spread over a long period. For around two years Rachel has helped a woman widowed during the pandemic.

Rachel said: “Her husband sorted all the household bills and arrangements. Then suddenly he’s gone and she doesn’t know how to unpick all that because everything it’s in his name. I’ve helped her navigate solicitors, banks, finding her a reputable handyman and a window cleaner, things like that.”

In Workington, Kelly said: “We can look for gaps in services. We are looking to set up a menopause group, because we feel that a lot of women coming to the surgery are presenting problems that all relate to the menopause. We’ve got a wellness day in schools and a weight loss clinic.

“And one guy we helped get £15,000 because he wasn’t claiming the benefits he should have been. We’ve had some really good success stories.”

One of the challenges of the UK’s ageing population is enabling people to live independently for as long as possible.

Most often, even when they need more specialist support, the last thing elderly or frail patients want is to leave home and be hospitalised or in permanent care.

This is where the newly developed role of frailty co-ordinators can be a huge benefit. These specialists now operate within many GP surgeries across North Cumbria.

Louise Fitzpatrick, Frailty Lead with Carlisle Network Primary Care Network, explained the role.

She said: “The main aim is to ensure that our older population’s wishes are respected and we look after them the way they want to be cared for. Our role is also to reduce avoidable hospital admissions, reduce GP workload, and make sure patients are seen by the best person.

“We’re not just looking at the medical side of their care, but holistically, and we use the full team for that.”

Kayleigh McLeish, Frailty Care Co-ordinator for Carlisle Network, added: “We develop a care plan with patients, to identify areas where they may need more support in their daily lives. We aim to keep patients at home and independent and avoid unnecessary hospital admissions.”

Each care co-ordinator has their own caseload of patients, so they get to know each one individually.

Katie Ross, Frailty Care Co-ordinator with Carlisle Healthcare, the city’s other Primary Care Network, said: “We look after a lot of patients in their own home, those that maybe can’t access the surgery. We go out and listen to them and find out what their needs are.

“It’s about finding out what they need support with, what’s important for them, rather than telling them what they need support with.”

Stacey Kelton, also a Frailty Care Co-ordinator with Carlisle Healthcare, added: “We’re the link between patients and the rest of the team at the GP practice. We go out and see the patient and have a good chat with them.

“We may be there an hour or two and we’re able to feed back any concerns to the wider GP team.

“I love going out and seeing the patients in their own environment, listening to their storys and being able to help them at the same time.”

Building up that trust plays a significant part in ensuring patients can access the help they need.

Stacey said: “I worked with a lady who didn’t attend her hospital appointments. For whatever reason she was not comfortable going. I tried to visit her at home but was unsuccessful.

“But we met at a coffee shop, built that rapport and I’m now able to assist her so she can get to her important appointments. She thanks me all the time for just taking the time to sit and talk to her.

“The NHS can be complex and intimidating and our role helps people navigate it a bit better.

“We can support people to get back on their feet with their social challenges and we’re someone they can phone and be that first port of call.”

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It can take the skills of the whole GP practice to solve an issue that’s causing or worsening a medical problem.

Stacey Kelton said: “Some people have high blood pressure because they’re in debt, or their housing environment is not safe, or it might be the heating’s not working.

“If we get involved we can support them, because we have links with lots of agencies, and that helps the underlying issue. We work with Age UK, Citizens Advice, housing associations and many others.”

Anyone who has ever suffered debilitating back or neck ache knows the misery the pain and restriction of movement can cause.

Such issues are commonplace, in fact musculoskeletal (MSK) health issues like these are the most common cause of repeat GP appointments, accounting for around one in five of all appointments.

The good news for under pressure GP surgeries is that many problems can be dealt with effectively by a physiotherapist, without any need to see a doctor.

In North Cumbria, First Contact Physios (FCP) have become part of the team at some GP surgeries after Workington was a successful local and national pilot.

The role of the FCP in primary care is to assess patients with soft tissue, muscle and joint pain and decide on the most appropriate management of that injury or condition.

Sima Moyo is an FCP with the James Street Group Practice in Workington Primary Care Network.

She said: “Our day-to-day job is to see patients who would normally go to a GP for things like back, neck, knee or shoulder pain.

“With the new model of care, the receptionist will establish what kind of problem it is and navigates them to the appropriate practitioner, such as the MSK clinic.”

FCPs operate in a similar way to a GP, so the patient attends consultation for assessment. The FCP will establish the problem and the service needed. They refer for follow ups like X-rays, blood tests, core physiotherapy, or to orthopaedic surgeons and for elective services.

Sima said there’s a growing awareness and appreciation of the role.

“People now use the service more and seem to appreciate they can come directly to somebody who deals with musculoskeletal problems and they feel that is the best way to be seen.

“We can give them advice, such as exercises, there and then so this reduces the number of people who have to be referred on for physiotherapy and wait longer for treatment.

“The job is quite challenging; you see new patients and new conditions daily. But it’s satisfying because you can refer them and you have opportunity to follow them up. Patients can always come back if they don’t get better and that is quite reassuring.

“The feedback we’ve got from both clinicians and the patients has been positive.”

Such is the demand for the services, two FCPs are now in post with Workington Primary Care Network offering daily clinics.

Fellow FCP Tamsin Cass said: “Some patients are very pleased just to be seen and are very thankful. I have had a few who have come in and said ‘no offence, but I want to see a GP’ but normally when you explain your speciality they are fine with it.

“We are specialists in MSK, we have good connections with the acute trusts and the orthopaedic service so we can ask direct questions there. We can give patients a better journey, quicker hopefully, so they see the right person, get the right investigations and the right advice from the word go.”

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First Contact Physios are becoming more established nationally – but there’s an important emphasis on understanding regional issues and pressures.

Sima Moyo said: “We have to understand our population, although it is now a national service it takes into consideration local needs.

“Workington is an area of social deprivation with a lot of mental health problems, and sometimes there is an overlap between physical and mental health so it is important we collaborate our work with others, such as the social prescribers.

“It is a very satisfying job in that we can all work together to meet the needs of our population.”