A commitment to coordinated care has proven to be a game-changer for a Yorkshire Primary Care Network (PCN).

South Hambleton and Ryedale PCN in north Yorkshire consists of seven practices with a combined patient list of 35,000. Situated in rural region and small locality, the area’s demographic includes many frail and older patients who require unique care strategies to meet their specific needs.

Dr Paula Evans, Clinical Director of South Hambleton and Ryedale PCN, and Dr Andrew Lee, Vale of York CCG’s Executive Director of Primary Care and Population Health, told Healthcare Leader the steps they took to create a care coordinator role and successfully bridge the gap between health and social care.

The problem

‘In essence we are a set of small market towns,’ explains Dr Evans.

‘We have a disproportionately older population and actually our population lives to ripe old ages, we often have patients over 100. They are a great population, obviously such great longevity but of course, this does mean that we have to get used to all of their needs. Sometimes, when patients are on their terminal decline, it’s pretty quick – so we have to be quite responsive.’

In rural PCNs, it may feel as though practices are invisible compared to the urban networks, which are often far louder when demanding more funding or resources. Populations in rural areas can quickly become marginalised, therefore taking a proactive stance becomes vital when advocating for patient needs.

Caring for an older population poses unique challenges. Many older patients often several long-term conditions at once, making monitoring their health a considerable challenge.

‘As a GP, you often feel like you’re playing snakes and ladders each day. One day you land on a ladder with a patient and you go up the rungs and you get the solutions that your patient needs. Other days you slither down to the bottom again,’ says Dr Evans.

Linking up care in a region where it often takes 45 minutes to drive between practices, let alone to the nearest hospital, takes precious time away from health professionals. There was significant gap in support, but first the PCN needed to define what this gap was.

The method

While PCNs have only been in operation since 1 July, practices in this area have a long history of working collaboratively as part of a GP federation. This dialogue has been going since 2013, gradually bringing together several health organisations, charities and government institutions, such as York County Council.

Before drawing up an action plan, the practices first needed to find out what their population needed and how they could provide for them. Using an electronic frailty index (EFI), which came into use in 2017, the practices began to collect data and identify patients at risk of certain conditions, including dementia and frailty.

‘We were able tocollect the data from the very beginning, and we were able to link that to hospital admissions – recording our conferences on the enhanced summary care records. We started the measurement early in order to get an idea of how we were doing and to evidence it.

‘Certainly, our CCG were convinced by it, certainly proof of concept that we’ve demonstrated within the frailty coordinators.’

Proving patient need was key to getting action underway, and it allowed for a better understanding of the challenges of caring for this population.

The solution

Having seen cancer care charity, Macmillan, working with care coordination in secondary care, it seemed like a logical step to borrow the concept and move it to the primary sector.

Gillian Barratt took up the role of care coordinator. She came from a banking background, and with it brought a unique and fresh perspective on how to link up healthcare for each patient’s individual needs. Ms Barratt’s position was then solidified with NHS England development money, in what’s called the £1.50 per head. The PCN has now appointed a second care coordinator, focused specifically on dementia care, to better meet its older population’s needs.

From a clinician’s perspective, explains Dr Evans, bringing in someone not from a health background has been hugely refreshing. The care coordinator can look at things from both a patient and carer perspective, which allows for gap analysis.

The Vale of York CCG’s Dr Lee has also found the role to be not only beneficial for the primary care team across the PCN, but also for patients who have easier access to care. Dr Lee was impressed by the PCN’s use of data collection. Instead of the proposal being a ‘flight of fancy,’ says Dr Lee, ‘It was nice to see them actually looking at the data and trying to make sense of what the population really needs. What does the community really need? What does the data say? Does it match the day-to-day experience? Based on that, they said, “yes, there is a need”.

‘The patient feedback is great. That’s what matters.’

The new dementia coordinator will take up their position in October 2019, but the PCN has achieved much more in the meantime. A Parkinson’s nurse has been appointed, with the support from the Parkinson’s Society, and a partnership with York Teaching Hospital has been established. A rapid cancer diagnosis pathway has been piloted, and there has been a considerable increase in prescribing reviews in the elderly population.

Dr Evans concludes: ‘The care of our patients is a lot more organized and anticipatory, and [there is] less crisis. But actually, more importantly, it works.’