6. South Durham Health Community Interest Company (CIC)


6. South Durham Health CIC

Overview

Four practices have united with several providers around a new vision of care and are pioneering innovative new services for people with mental health, chronic pain and long term conditions. South Durham has high levels of unemployment, deprivation, mental illness and chronic disease. The primary care home offered a flexible model for the three large practices in Newton Aycliffe and a smaller practice in Shildon to collaborate with other partners to improve services and to work together better.

How things are changing

To address the high levels of adult male suicides and reduce the delays in accessing treatment, community psychiatric nurses (CPNs) are based in GP practices so patients with mental health needs can be directed to them immediately. Co-operation between the three Newton Aycliffe practices has meant the CPNs are treated as a shared resource and patients can be referred to whichever practice’s CPN can see them first. Shildon was the first to pilot CPNs being based at the surgery, this was then rolled out to the other practices (and across the clinical commissioning group) following positive evaluation. The move has generated positive feedback from patients and GPs.

Chronic pain had traditionally been treated in secondary care with medication. The primary care home has piloted an eight week course in mindfulness at its Shildon practice which is now being rolled out across the other practices.

The PCH has focussed on improving self-care for patients with diabetes through the Insignia Patient Activation Measure (PAM). The measure is used to rank patients at one of four levels of activation of care, patients at the lowest levels are being proactively referred to services that can support patients achieving lifestyle and behaviour change. Following a programme of tailored support, patients will be reassessed for a change in their activation measures. It is planned to incorporate the measure into patient annual reviews.

Lessons learnt include the need for everyone to be able to see they are having a positive impact. Staff need to feel welcomed as part of the practice team even if they only spend a limited amount of time there.

Partners

Four practices, County Durham and Darlington NHS Foundation Trust (acute and community services), Durham County Council, Macmillan and other voluntary sector organisations.