5. Aspire Integrated Rugeley (AIR)


5. Aspire Integrated Rugeley (AIR)

Overview

Rugeley is an old mining town which has a population with a higher than average prevalence of long-term conditions. There is a lot of respiratory disease in adults who worked in the mines and a fair amount of health inequality locally. Two of the four GP practices used to be one large practice and are now working together again as part of the primary care home. The vision is for out-of-hospital care to be delivered locally to avoid unnecessary hospital admissions, to improve whole population health outcomes of the local community across all age groups and have a proactive, health and wellbeing agenda.

How things are changing

To cope with rising demand for urgent care, the primary care home has set up an overflow same-day appointment clinic with each of the four practices taking it in turns to host the afternoon clinics. As well as GPs, patients are being seen by advanced nurse practitioners, urgent care practitioners and physician associates. A community-based dressing clinic has been started to integrate community nurses into primary care and treat patients in a social setting where they meet others and receive falls prevention advice.

There is now a redesigned service with the community trust to support patients in a large care home, which had a historically high demand for GP visits. Under the new pathway, there is leadership support for care home managers and the home contacts an advanced nurse practitioner initially to discuss any concerns. The nurse practitioner then pulls in additional support when needed. Early indications are that this is working well and requests are falling.

Patients with long-term stable conditions are being supported with telehealth. Teams of experts from hospital, community and primary care offer clinics to patients in surgeries. This expert approach has been shown to work with 19 out of 20 patients with respiratory conditions who would have normally required admission.

The primary care home is working with the acute hospital on a whole population health programme involving schools, universities, Tesco and other big employers. The programme aims to raise awareness of health and care careers and become ambassadors and promoters of a healthy body and mind.

Lessons learnt include that the primary care home seems to resonate with GPs, working as a bigger team and giving them a degree of resilience makes it feel like it will work. It is hoped it will lead to better patient outcomes, improved health for the local population and a reduction of stress and overwork for GPs.

Partners

Four GP practices (Aelfgar Surgery, Brereton Surgery, Horsefair Practice and Sandy Lane Surgery), GP First Federation, Staffordshire and Stoke-on-Trent Partnership NHS Trust, Cannock Chase Clinical Commissioning Group, University Hospitals of North Midlands NHS Trust and patient representative.