Newport Pagnell Medical Centre Primary Care Home

Newport Pagnell is a small market town, on the outskirts of Milton Keynes – probably best known for being the home of luxury cars including Aston Martin.

It is also home to many older people – the population is older than that of the rest of MiltonKeynes with 8.5% over the age of 75.

We know that older people experience a range of medical and social problems that are distinct from those experienced in younger age groups they include social isolation, depression, frailty and multiple chronic conditions often resulting in the use of many different types of medication.

Our Newport Pagnell primary care home uses an innovative community matron model that ensures that older residents receive targeted care both to keep them well and to manage ill-health. The team also sees any registered patient below age 75 years if they need their care.

So what does the community matron team do in this model? Firstly, every new resident over the age of 75 years, within our practice boundary, receives a well-being visit from the community matron team within six weeks of moving into the area. This visit is to create a link between the resident and the practice. Newcomers are given information about the practice, local voluntary sector organisations and a team contact should they need more help.

People’s health and care needs are noted at that visit and arrangements are made for support from social care services and help with finances where necessary.  We want people to feel welcome and aim to create a sense of partnership with them when it comes to their health and care needs.

Patients with long term conditions receive a general check and recommendations for the best possible care. We might, for example, provide them with a pill organiser box, arrange a medication review or book an appointment with their GP or long-term condition nurse if a medical review is needed. The team also helps to arrange patient transport to clinical appointments. When patients become more unwell or dependent, their first port of call is often the community matron team which will help them navigate the health and care system. This group of patients tend to be high users of secondary care services when their health deteriorates. We believe our community matron model has helped to buck this trend.

The team also provides support for other wider issues such as power of attorney forms,  council tax exemptions, memory assessments and medical reports to help patients with a terminal illness claim benefits.

One of our community matron team members is a trained counsellor and is able to offer counselling support for patients and carers The link between long-term conditions and mental health is well documented and using counselling skills with this group of patients and their carers goes a long way to alleviating some of the debilitating effects of anxiety and depression.

We also recognise the role of carers in looking after older family members. The community matron runs a special support clinic for carers to ensure they remain healthy and are able to continue their caring role.  We are not aware of any other clinical role currently within the NHS that provides this service. There is now a well-established carers’ group in the area, where new carers can receive support from peers who have been in similar situations.

The matron team also works with local voluntary sector agencies which are a rich source of information for all medical centre staff on social prescribing initiatives. We’re in the process of developing a local directory of services, building on the knowledge of local services already used by the community matron team.

So, what are the benefits of this model of care? We have one of the lowest admission rates to secondary care for the over-75s across Milton Keynes, despite having a larger percentage of older residents in our area. Satisfaction with the service is excellent among patients and their relatives. The community matron team is well-known in the local community and people really feel that they can get involved in local community activities.

Our aim now is to build on this model and target other age groups with similar needs. We are also sharing our learning with the local clinical commissioning group (CCG) and there’s a project looking at implementing a similar approach across the whole of Milton Keynes.

Do you want to target a specific group in your population? Do you want to improve care? Or save on admissions? Then consider this tried and tested model of healthcare. We would be happy to share information with any primary care home, network or practice wishing to boldly go where few have gone before!

Get in touch via napc@napc.co.uk

Dr Omotayo Kufeji
Newport Pagnell Medical Centre Primary Care Home