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Profile: Alternative vision

4 March 2014

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Housed under the same roof as a range of community health clinics, Nelson Medical Centre offers a seamless service for patients

In the seaside town of Yarmouth, Norfolk, general practice is getting alternative. Instead of the usual contractual arrangements of general medical services (GMS) Nelson Medical Centre is part of a social enterprise, East Coast Community Healthcare (ECCH), and run under an alternative provider medical services (APMS) contract.

This is important as it allows the practice to set its own targets rather than having to adhere to those set out in the soon to be dramatically reduced quality outcome framework (QOF).

Practice manager Lindsey Smith, who has been with the surgery for 13 years, says this allows the team to provide care appropriate to the surrounding community – a community which is hugely diverse.

An in`crease in migration to the area has resulted in a sixth of the practice list hailing from overseas. Communicating with these patients is a core challenge for the practice.

Lindsey and her team do this in many and various ways including sending out letters in a variety of languages including Polish, Portuguese, Lithuanian and Cantonese. 

Of course the need to communicate in consultations with patients who don’t speak English is all the more pressing so the practice has a phone translation service to hand to help with this.   

“The doctor has the interpreter on loud speaker with the patient sitting there and they have a three-way conversation,” says Lindsey, who started off at the practice as a data entry clerk before becoming completing numerous management courses including the diploma in primary care management.

However with it being a three-way conversation, there have been times where a clear concise consultation has proven to be a challenge, and it can also be time-consuming as doctors have to wait for an interpreter to become available adds Lindsey.

Given the difficulties that can be encountered, a double appointment is scheduled for these patients.

The concept of primary care is not universal and often patients from ethnic minorities can be confused by the NHS referrals system.

“We do find that people from different ethnic groups can bring us specific challenges because their health needs and their expectations are slightly different…Patients don’t always understand the processes involved in making a referral. Some patients think they can come in and see a gynaecologist in the surgery. It’s about sitting down with patients who’re a bit disgruntled about not being seen as swiftly as they hoped and explaining how it all works. They then leave the surgery a lot happier and content with our pathways referral,” says Lindsey.

The practice also has to work hard at getting this population involved in cervical screening and child immunisation, which come under directed Enhanced Services (DES) and QOF targets for all general practices. 

Lindsey says: “We know that within our local area, cervical screening and child immunisation has always been difficult. With the groups of patients, we work with, some are non-compliant, so we’re tasked to improve the statistics for the health needs of our patient population.”

A lack of health education stemming from poverty and the transient nature of the population are the main factors that contribute to the low uptake of these initiatives, Lindsey explains.

The cultural differences arising from the diversity of ethnic groups also means that some patients are less likely to be aware of the benefits of cervical screening.

One of the innovative ways the practice tried to reach out to patients was through a project  to send out birthday cards to children with a reminder that immunisations were due.

Also the practice nurses actively telephone parents to offer them appointments and the surgery also provides open access where patients can be immunised while in the surgery for other health appointments. 

For cervical screening, the practice was involved in a pilot project to support the development of the communication skills of receptionists and the cervical screener to improve the journey from making the appointment to having the smear test.

For example, as the first point of contact, the receptionists developed their technique to support patients in booking an appointment by discussing the screening process.

As a community interest company, all practice staff are entitled to have a £1 share in ECCH if they so wish, and any profit that is made is reinvested into its services.

“All surplus monies generated by ECCH are invested directly back into patient care of into the business to benefit patients. In our first year, we purchased equipment for other areas of the organisation. This year, we have invested surplus monies into a research post,” says Lindsey.

Although staff do not get to pocket any profits as a shareholder, they all have a voice about how the enterprise is run.

Lindsey says that as a social enterprise, there is a clear identified focus with everyone working towards the same ECCH goals. 

There is also a clear organisational structure with a chief executive at the top, a full board that everyone reports to, and clear communication lines.

Nelson Medical Practice hasn’t always been run under an APMS contract. 

When Lindsey first joined the practice in 2000, it was run under a single-handed GP, before being taken over by a primary care trust in 2003. 

It was then housed in a porta cabin while waiting to be rebuilt. 

After a long extended wait, the practice was finally re-housed in its current location in 2010, where a need for a practice to be built in the area had been assessed following 25 years of campaigning by local residents to local councillors. 

Previous to where the practice is now situated in Cobholm and Lichfield, there had never been a GP surgery, and in 2005 when plans for the surgery were developed, there was a lengthy consultation process where a forum was developed and the primary care trust (PCT )worked with the forum group to ensure the building met the expectations of the local community.

Originally under the umbrella of community services in the PCT, the practice was then taken over by ECCH in 2011 when arms length community services were disbanded. 

Occupying a purpose built building, Nelson Medical Practice is housed under the same roof as a range of other community services including smoking cessation, incontinent services, chronic fatigue syndrome, contraception and sexual health services as well as Doppler, leg ulcer and dressings clinics run by district nurses. 

The area Abdominal Aortic Aneurysm (AAA) screening team also holds clinics at the practice.

Although patients still need to undergo a normal referral process to access the services, there is a central reception that does a meet and greet for all services, which is run by Nelson Medical Practice.  

The central reception holds the booking lists and directs patients to appropriate areas.

Practice manager Lindsey says that having a range of community services under one roof aids communication among staff, providing more integrated care for patients:

“For community services, all the GPs work together in the sense that we sign-post, we communicate effectively; we ensure that the patient experience and the pathway is seamless through our community teams. We’ve got good relationships, we’re all one organisation, we support each other, and if there’s a clear issue with a patient, we’ll always try to support them and liaise in the best interests of the patients.”

The services provided by ECCH comes under three business units, including adult’s services, children’s services, and primary care and prevention. Regular meetings are held between the heads of the three business units to discuss a topical agenda, the contents of which are shared throughout the wider organisation. 

The Nelson Clinical Practice clinical team also offers clinical advice to district nurses running clinics out of the centre if needed, as well as administrative support to the other community services.

Furthermore, having all the services under one roof is also very convenient for patients as they can receive treatment for secondary care needs at the same place they receive primary care needs.

“For patients who don’t want to travel far, especially as it’s a deprived area and many of the patients are on low income, it’s like a one-stop shop for some of them. They come for primary care needs, but also get treated for secondary care needs. Patients feedback is that it’s like a seamless service.”

Patient satisfaction has been rated as ‘very high’ in 99% of patients in the quarterly surveys held by the practice. 

As part of a social enterprise, there are also more services available to patients. The building is also open 24-7, serving as an out-of-hours base. Patients who’ve had the need to use the services have responded very positively regarding the range of services that are available.

The Nelson Medical Practice has recently become a research ready practice, as well as a Teaching and Training Practice.

As a research ready practice, the surgery’s main aims are to improve patient care and speed up access to the best treatment and care for people across the country.  The practice works with representatives of the Primary Care Research Network (PCRN) to achieve key research objectives including increasing the number of patients recruited into PCRN portfolio research studies. 

“Since September, we have been involved in a number of studies in which we contact our patients with specific clinical criteria for consent to enroll in a study with the support of the clinicians in the practice,” says Lindsey.