10. Wolverhampton Total Health

10. Wolverhampton Total Health


The primary care home has helped to stabilise and unite a group of eight GP practices struggling to deliver services in an area of high need, and develop new services focussing on the frail elderly, access and diabetics. Small GP practices were struggling with severe health inequalities together with an uneven distribution of frail elderly and diabetic populations which skewed demand. They were struggling to recruit staff and lacked the scale to bid for additional funding. It was clear that greater integration was needed to create a sustainable basis for providing specialist multidisciplinary care which in turn would reduce demand on health and care services.

How things are changing

An integrated multidisciplinary team has been created to run severe frailty clinics focussing on care and prevention for the frail elderly. The team consists of a health care assistant and a senior clinical pharmacist. Each patient has a complete geriatric assessment covering mobility, exercise, hearing, vision, incontinence, medication review and lying and standing blood pressure (a good predictor of falls risk). The PCH has also linked up with the Fire Service who make ‘safe and well’ visits to people who have recently fallen.

A virtual diabetic clinic and an insulin initiation service have been launched, with support from pharmaceutical companies, to speed up increased medication for poorly controlled diabetics and reduce the need to refer into the hospital clinics. Run by a specialist diabetic nurse and GP, the clinic offers advice while practitioners see patients in their surgeries.

The scale of the PCH has enabled it to bid for funds for additional services which individual surgeries were too small to bid for. Winter pressure money has been used to run additional surgeries over the Christmas bank holidays and Saturday mornings. These are held with the second primary care home in Wolverhampton with three practices acting as hubs in the city to cater for their combined 100,000 patients.

The EMIS IT systems from all practices have linked up enabling the hubs to access a patient’s full records provided they give consent.

The PCH has been involved in running several pilots to help the clinical commissioning group (CCG) look at new services. In-house counsellors have been introduced following a bid for additional CCG money and social prescribing clinics funded by the city council. Both have proved successful.

Lessons learnt include that establishing a PCH takes much time and commitment – the GP lead is paid four hours a week to support it but spends two days a week on the PCH.


Wolverhampton Total Health (eight practices: Newbridge Surgery, Whitmore Reans Health Centre, Fordhouse Medical Centre, Tudor Medical Practice, Church Street Surgery, Caerleon Surgery, East Park Practice, Keats Grove Surgery), Wolverhampton Clinical Commissioning Group, the local authority’s public health team, Refugee and Migrant Centre, West Midlands Fire Service, Royal Wolverhampton NHS Trust.