13. Luton Primary Care Cluster

13. Luton Primary Care Cluster


Cambridgeshire Community Services NHS Trust and two GP clusters came together to design and deliver services targeting groups in the community with significant needs. They focused on older people with multiple medications and patients with type 2 diabetes. The primary care home model was a flexible solution which enabled them to collaborate and deliver services in a way which met the needs of their patients and their organisations.

How things are changing

The rapid test site were aware of increased use of medications in the elderly population and concerned about the adverse outcomes, such as hospital admissions and falls which can be associated with polypharmacy. With limited resources, Medics United cluster looked at how they could work differently to support patients, particularly those over 75 years taking ten or more medications. Using funding as a rapid test site, they employed a clinical pharmacist for a 12-week pilot (September to December 2016) who visited surgeries and housebound patients, explaining and reviewing their medication in a one-hour consultation, reviewing their adherence to their medication and assessing their risk of developing an adverse drug reaction or admission to hospital. Since the pilot, community pharmacy technicians have followed up with patients and monitored the impact of the reviews.

Luton’s population has a high prevalence of diabetes. Many primary care colleagues had highlighted that their type 2 diabetes patients were not understanding fully the condition and this was leading to complications. Kingsway cluster targeted patients who were struggling to self-manage their condition with a HBA1C score of more than 80 (levels of glycated haemoglobin indicating average blood sugar levels) with repeated failures to attend GP, retinopathy or podiatry appointments. Patients were asked to attend specialist clinics for a one-hour consultation with the community diabetes team (clinics in Urdo, Bengali and English). The team discussed with patients how they were managing their condition and used the Patient Activation Measure (PAMs) to tailor their approach to supporting and motivating them. After the appointment, patients can attend weekly group sessions for four weeks giving them an opportunity to share experiences and information, learn more about diabetes and living with a lifelong condition, support other attendees and make new friends. The rapid test site is in the process of piloting this pathway, so no evaluation is available.

Lessons learnt include that engagement with all stakeholders is key in the design, planning and implementation of the pilots.


Nine practices (Barton Hills Medical Group, Bell House Medical Centre, Woodland Avenue Practice, Gardenia and Marsh Farm Practice, Kingsway Health Centre, Pastures Way Surgery, Conway Medical Centre, Medina Medical Centre and Wenlock Surgery), Cambridgeshire Community Services Trust, Luton Clinical Commissioning Group, patient groups, Healthwatch and LiveWell Luton.