The Eden Primary Care Home was created by local GPs from four practices struggling to recruit staff and sustain services who wanted to change the way they work to improve services for their isolated and older population in Cumbria. Developing a primary care home was seen as a way of creating sustainable, integrated services which better met the needs of the population and made their organisations more viable.
Their vision is to provide better care for patients, through an integrated service which avoids many different visits from different service providers and brings care closer to home avoiding the need for patients to travel miles to hospitals in Whitehaven, Carlisle and Penrith.
How things are changing
The primary care home has led to more integrated working between GP practices, and between district and practice nurses. It has enabled a number of specific projects including the introduction of new non-clinical services to meet patients needs and reduce the demand on GPs. Small local changes have been able to happen quickly while large scale plans as part of the Cumbria Success Regime and developing a Cumbria-wide integrated care community have been worked on.
Among the new services introduced has been Listening Ear, which provides confidential listening to people’s problems and signposting to services which can address social and physical isolation, ranging from coffee mornings to mindfulness classes, dancing and Tai Chi. This has eased the pressure on GPs from patients who have social rather than clinical needs. Dressing clinics have been moved out of surgeries into the community, for example, to village halls and churches to make them more sociable events where isolated people can socialise. The council’s public health department has also employed health and wellbeing coaches to try to prevent childhood obesity and reduce the burden on health services.
Other projects include a review of patients receiving vitamin B12 injections, this found that only 20 of 66 people receiving them needed to, reducing appointments and district nurse visits. For patients with chronic obstructive pulmonary disease (COPD), the primary care home is moving services into the community so people will no longer need to travel to Carlisle. The PCH has introduced new technology to enable self monitoring of blood clotting for people with chronic disease, putting them in charge of their care and reducing the need for district nurses to visit.
Lessons learnt include that it has been hard to take forward all the desired changes while wide-ranging reforms to the organisation of services are underway.
Cumbria Clinical Commissioning Group, North Cumbria University Hospitals NHS Trust, Cumbria Partnership Foundation Trust, Cumbria County Council (social services and public health), Cumbria Council for Voluntary Service, and the Bishop of Cumbria.