Enhanced Primary Care

All Together Better is made up of three distinct parts. Enhanced Primary Care is one of them, and it will see GPs in Sunderland work to create a better model of care.

As part of the Vanguard Enhanced Primary Care Programme we are aiming to deliver a programme of projects which enhance clinical quality, release capacity in the healthcare system and provide opportunities for GP’s to work together collectively and collaboratively at scale in line with national expectations.

This part of the programme is being supported by the Sunderland GP Alliance, who now has a membership of 44 of the 48 GP practices in Sunderland. Representatives from many of the city’s GP practices, who are often closest to the individuals living with long term health conditions, are introducing a number of projects and initiatives to see how they can best support their patients. They are committed to promoting the best possible level of care, whilst also ensuring it is delivered in the most efficient way possible.

Map of medicine is one such successful project that has been rolled out across the city; this is the development of localised pathways and is accessible to all clinicians in general practice to improve information at the point of care. This system ensures a timely referral process to other professionals when required, as well as provides a comprehensive signposting resource to other services and agencies city wide.

EPC is supporting the movement towards care home alignment with GP practices in Sunderland. There was an unsustainable demand on GP capacity for visits to care home residents. A situation had evolved over time where there were GP surgeries who were dealing with the co-ordination of care for up to 74 patients in 22 different care home locations spread across the city. The alignment process will release capacity for both care home and GP staff by preventing duplication of effort in liaising with multiple GP providers to arrange visits for residents. It also provides the opportunity to support more proactive management of the care needs of this group of patients.

EPC is also implementing a couple of Post-discharge Services; following discharge for an unplanned medical hospital admission a clinical signposting and triaging system is underway where those people are managed in a more proactive manner to help reduce further unnecessary hospital admissions. Care will be person centred, ensures the patient sees the correct professional involved in their care, includes the option to have new and /or existing medications reviewed by a pharmacist, be referred onto other services, for example, the Community Integrated Team, or have a holistic assessment and follow up by an experienced nurse to ensure they are receiving the necessary healthcare and advice to prevent future avoidable hospital admissions.

A community clinic for COPD and asthma patients has also been established in two locations within the city to help support City Hospitals Sunderland with their post-discharge follow up demand; these are operated by a respiratory nurse specialist. This allows capacity for those people, often referred from general practice, who need a hospital consultant review to be seen by the correct professional in the correct location.

Other services that are being developed are operating in a ‘hub’ model across the city; one such example of this would be the facility of patients being referred to a practice in a locality area to have an Ambulatory ECG, without the need of waiting for a referral to secondary care.