Rural GP practices can face very particular challenges in the running of their everyday services. Having a smaller population spread over a wider area means it can be more difficult to engage with hard-to-reach patients.
Exmoor Medical Centre in Somerset, rated outstanding by the CQC, has found an innovative solution to this issue by working closely with partner neighbourhood organisations to develop a rural health hub in a farmers’ market.
Senior practice manager, Lindsay Smith, and GP clinical lead at the practice and clinical director at West Somerset PCN, Dr Kelsey Boddington, talk to Management in Practice about the project and how collaboration is vital for its success.
How did the rural health hub start and why?
Dr Kelsey Boddington (K): Exmoor Medical centre is a 4,000-patient practice that covers over 300 square miles across Somerset and Devon. It’s in an extremely rural, isolated and large area with high deprivation levels, poor public transport links and poor social mobility.
We get to know our patients well and we identified that there was a particular cohort of patients – the local farming and agricultural community – who do not always access healthcare. We’ve got patients who would often rather prioritise their animals’ health over their own.
There was a rural health drop-in at another farmers’ market in Somerset that was established in response to the tragic accidental death of farmer Derek Mead. The hub for the farming community at Sedgemoor Livestock Market provides health screening from district nurses, and referrals to GPs or other health professionals. The clinic flourished and was visited by the Princess Royal and the then Lord Lieutenant of Somerset, Annie Maw, in 2019. It was also recognised by Somerset NHS Foundation Trust, so it was thought a good idea that this model should be expanded.
There’s been a farmers’ market in our area for a while and several of our local organisations got together to establish a similar health hub for Exmoor. The idea behind it was to take a different approach – rather than having to work hard to encourage farmers and very rural patients to come to us at the surgery, we would take healthcare services to them.
We had already established a precedent of working together with local health and care, as well as voluntary organisations in West Somerset. This joint work is mainly as part of the West Somerset Neighbourhood, (also known as Living Better), a network of local organisations including the local hospital, GP practices, the Community Council for Somerset, and charities. Since the aim of the group is to support the community with health and wellbeing, the idea of the health hub fits naturally with the group’s work.
The idea was first discussed by Living Better in 2018, but we launched in Spring 2019 after getting funds from ICS pilot project funding and help from the Lord Lieutenant and Police Commissioner. The hub is held roughly once a month although more frequently during some months.
What healthcare services are offered at the farmers’ market?
K: Our district nurses, who have been there from when the hub was first launched in Spring 2019, provide health checks, including blood pressure, weight, pulse, alcohol screening, smoking status, family history and any current health problems.
Our care coordinators joined the rural hub team later in Autumn 2021. They input health data into EMIS and action any onward referrals, such as to PCN pharmacy teams.
We also have recently added mental health practitioners to the team and as well as chiropodists who offer treatments including for nail conditions, orthotics and general foot care.
There are plans to expand what we offer – we’d love to diversify the team to include social prescribers, but recruiting for these posts is difficult.
Was this scheme difficult to get off the ground?
K: Sometimes ideas like this don’t come to fruition, but we found that having a strong neighbourhood network really helped to bring it together. We had to build lots of relationships and trust via all the joint working we have been involved in locally.
There was a lot of work we had to do with the local community and markets to get it started. For example, we spread the word about the hub by advertising in village shops and parish noticeboards. The Farming Community Network, a voluntary organisation, welcomed the idea of the hub and helped to raise awareness of it.
Beyond spreading the word, IT systems have been an obstacle we had to overcome. At first, when farmer attended the hub and was seen by a district nurse, that didn’t used to be documented in our primary care record. Now we have our care coordinators involved, they can input all the data into our practice system EMIS, which ensures we can access shared records.
Are there any other challenges you’ve faced, or still face?
K: Because primary care services are so stretched and we don’t have all our job vacancies filled, it’s a challenge to deliver the service.
In an ideal world, we would be able to send a GP alongside a care coordinator, social prescriber and mental health practitioner. But we cannot spare any more professionals from the front line.
Providing the service relies on many staff working above and beyond. Rostering is a challenge, and often depends on the time of year and the number of markets there are a month.
What benefits has the rural health hub brought?
K: It has made a difference to those patients we find hard to reach, such as those who haven’t got time to come into the surgery for check-ups or appointments, or those that don’t prioritise their own health.
There was one patient, a farmer, we couldn’t easily persuade to come in for a blood pressure check. In the end, we asked them to go to the hub whilst at the market and within two weeks, we had obtained a blood pressure measurement.
Lindsay Smith: Our QOF list shows us all the people who still need to come in for reviews and so forth towards the end of the year. It’s usually the farmers.
Since introducing the rural hub, the number of people who are usually on that list has dropped.
K: Everyone is also really proud of the service. We take ownership of it as a team. The practice was awarded an outstanding rating by the CQC last July. Its report noted the practice’s work with rural patients and said we took a ‘truly holistic approach’ to assessing, planning and delivering care and treatment to its patients.
L: This recognition from the CQC was a massive boost for staff. We feel we have always go above and beyond for our patients but being recognised for this work after what has been a really difficult few years was very welcome.
What advice would you to a rural practice looking to run a similar health hub?
K: We can’t employ all of the people needed to run this service on our own as a small practice. So, close working with our PCN and neighbourhood has been key for us. I think it’s important for practices considering doing something similar to think about working with other organisations to make it work.
It’s also crucial to look at internal systems and utilising our PCN additional roles. We have a birth month recall system that encompasses all our annual reviews, blood tests and medication reviews. Using our care coordinators to input into EMIS has ensured we have up to date records. Also, having a system in place to refer patients, where appropriate, to our PCN pharmacy team has been valuable. All of this has helped deliver care to our patients in a more efficient and effective way.