Improving identification of and support for carers at practice level could contribute to a significant reduction in GP appointments for patients with mild to moderate frailty, a primary care network-led project has found.
It could also help cut A&E attendances, as well as emergency hospital admissions for patients living with frailty, the initiative in East Warrington PCN showed.
The project came about after GP practices in the network were facing unprecedented levels of demand from people living with frailty.
Patients with mild to moderate frailty had at least three times more GP appointments and 2.5 times more non-GP appointments than the PCN average. They also accounted for a disproportionate number of A&E attendances and emergency hospital admissions.
The PCN sought help from the Clinically-Led WorkforcE and Activity Redesign (CLEAR) programme, which is sponsored by NHS England. The CLEAR Proactive Care project in East Wrington was created with a remit to develop new ways of working to help GP practices and other health services meet the high demand for care from people living with frailty.
After interviewing more than 50 people from a range of services and carrying out a detailed analysis of data relating to 31,020 frailty patients, the CLEAR team identified that a lack of support for carers was a critical factor in rising demand om primary care services.
In particular, it found that carers were struggling to cope but were unable to access timely support. For example, GPs reported seeing carers with their own health problems, while the health of those they were caring for deteriorated. This led to carer arrangements breaking down, which was one of the main reasons for A&E attendance and emergency admission for frail patients.
It also found that key members of the primary care team were unaware of important information about local carer support options and how to access them. And systems for identifying and coding informal carers were inconsistent across the PCN’s three practices.
Improving identification of and support for carers was a key recommendation resulting from the project. To address this, the CLEAR team proposed that:
- Reception staff be trained to systematically identify carers when they first contact the practice on behalf of the patient.
- Practices could have a formal carers’ register and implement streamlined coding of carers.
- An alert system be put in place so that the whole practice team can see that someone was a carer when accessing their notes and all practices could proactively identify young and adult carers.
- A carers’ care co-ordinator role be created within primary care to work across practices.
The CLEAR project also made a number of other recommendations for directly managing patients with mild to moderate frailty, including introducing an ‘ageing’ well team to support primary care deliver more personalised, proactive care.
This team should consist of: an ‘ageing well’ advanced practitioner, a care coordinator, a clinical pharmacist and administrative support – and the carers’ care coordinator, already mentioned.
And the team ‘should link to a dedicated frailty lead GP in each of the three practices’ as well as oversee triaging of frailty patients to identify those most at risk and those needing referral to other services, it was proposed.
A uniform approach to coding frailty patients to enable earlier diagnosis should also be adopted.
The CLEAR team forecast that, if all its recommendations were implemented, the workload on GP practices at East Warrington PCN ‘would ease and staff morale and retention improve’. Annual savings of £144,339 could be achieved for the PCN based on a 50% reduction in GP appointments for moderately frail patients, a 30% reduction for mildly frail patients and a 30% reduction in A&E attendances and associated first-night hospital admission costs.
Dr Rakhi Raj, GP Principal and Clinical Director, East Warrington PCN, said the ‘robust data-driven recommendations’ on which the savings are estimated had been well received.
‘We’ve received positive feedback on the work from across the system and are currently looking to pilot the changes at the PCN in the coming year,’ she said.
The Association of Directors of Adult Social Services (ADASS) Carers’ Network has endorsed the CLEAR recommendations from East Warrington PCN, saying they are cost-effective ways ‘for carer support to be delivered directly to carers through primary care while reducing pressure on GP appointments’.
It has called for the recommendations to be promoted at national level.
Claire Brewster, who led delivery of the CLEAR proactive care programme, said: ‘Our project demonstrates that investment in carer support has major benefits not just for patients, their carers and general practice but also for the wider health and social care system.’
The national CLEAR programme supports clinicians and organisations to deliver transformation and workforce redesign projects.
