Enhanced Home Visiting Case Study: Roving GP Service - IC24

Overview
The Roving GP service was commissioned in 2009 with an initial remit to reduce hospital admissions. Since then it has evolved into an integrated resource to support Primary Care Networks (PCNs), GP practices and the wider Brighton and Hove system.

The problem
Brighton and Hove needed a flexible urgent primary care home visiting service that could respond to local need as and when needed. The service typically cares for these patients:

• Patients with urgent care needs who do not necessarily need to go to hospital, if they can be visited by a GP within a specified time period.
• Complex patients with multiple healthcare needs presenting with common problems such as falls and confusion.
• Paramedics who are on scene with a patient, who feel that the patient could be kept at home if a GP saw them urgently.
• Care homes by providing advice, visits and support to community services and covering urgent calls from specified care homes. As well as supporting hospital discharges and liaising with RACOP (Rapid Access Clinic for Older People) at University Hospitals Sussex NHS Foundation Trust.
  
  

Our solution
Working with local commissioners, Integrated Care 24 developed a fully integrated resource that provides a broad cohesive role across the system. This has been developed to accommodate the needs of local PCNs and working effectively with community, intermediate and responsive services. This includes supporting GP practices who are experiencing acute, unexpected and high level challenges. This was particularly important during the COVID-19 pandemic and has effectively demonstrated the value of such an adaptable service, in terms of both clinical care and practice sustainability. This key role was recognised by the CCG.

Lola Banjoko, Executive Managing Director at Brighton and Hove Clinical Commissioning Group, said: “We’d like to thank you for your help and intervention to support the needs of the residents in the care home during the second lockdown. Once again you have stepped in to pick up some real challenges within our health and care system which is hugely appreciated. The whole system’s response to supporting the care of residents in the home has been tremendous.”

Communication with PCNs is the key component to ensuring seamless care within the Roving GP Service. Referrals are taken via a clinician-to-clinician call, backed up by digital sharing of relevant information from GP records. Much of the success and good reputation of the Roving GP Service is down to the relationships that have been built over the years, including established links with commissioners and acute clinicians. Roving GP clinicians provide robust clinical assessments, diagnosis and treatment plans to keep patients out of hospital where possible. The care they provide is an important element in the rapid assessment of a suspected medical emergency.

The Roving GP clinical team consists of highly-skilled GPs, who form a cohesive, stable and fully integrated service. This multi-disciplinary clinical team have their own dedicated specialisms, which includes A&E, dementia, end of life care and advanced care planning.

Melanie Oldrey, Operations Manager at Craven Vale Resource Centre, said: The service we receive from IC24’s GPs is invaluable. Patients at Craven Vale have regular medical reviews which is instrumental to them receiving appropriate treatment in a timely fashion. This enables them to speedily regain independence and wellbeing by returning home, which is generally in line with patients’ desired outcomes. This team of GPs are clearly skilled and committed to offering a high-quality service, their approach to patients is friendly and person-centred.

The service currently provides up to 100 visits per month and avoids up to 80% of hospital admittances. This fully bespoke service can be scaled to meet geographical demand and local requirements.

Emma Bullock, Care Quality Director, at Victoria Nursing Group, said: The Roving GP service that covers our rehabilitation bed contract is invaluable. The GPs are very responsive and often prevent conveyances to hospital with their timely assessment and treatment plans. They are proactive and support with medication reviews and long-term health plans.

Key benefits and results

• Providing prioritised support to vulnerable practices or those experiencing acute, unexpected, high level challenges. Feedback from PCNs confirms significant contribution to practice sustainability, including the wellbeing of individual clinicians.
• Reduction in hospital admissions: 77% hospital admittance avoidance.
• Delivering holistic and coordinated same day urgent medical support to patients in their own home and in care homes.
• 99% of patients seen within 1 hour.
• Providing increased capacity and effective on-demand support to PCNs.
• A service that understands that every GP practice and PCN has different needs. We build effective partnerships to work across a county, flexing the service to suit the varying local needs and priorities of patients, commissioners and other healthcare professionals.
• 66% of referrals from patients aged 80+.
• Enhanced quality of life for patients with long-term conditions.
• Ensuring patients have a positive experience of care.