Micro-teams for better continuity in Tower Hamlets: we have a problem but we’re working on a promising solution!

‘We want fresh doctors’, a Patient Participation Group member requested during an engagement event in Tower Hamlets in 2014. He went on to explain that he no longer wanted to consult doctors who looked tired and distracted.

Tower Hamlets is characterised by high social disadvantage. People live with more illness, consult more frequently, and die younger, compared with more affluent areas. The number of patient contacts per GP is very high, resulting in both patients and doctors feeling more stressed after consultations.

Despite this, Tower Hamlets is a place characterised by clinical leadership that is collaborative, innovative, brave, and informed by evidence. Restoring relational continuity of care has been high on the agenda because it improves safety and is cost-effective, through reducing prescriptions, tests, emergency department attendance, and hospital admissions.¹

In 2007, all 36 practices responsible for the 270 000 residents were organised into eight geographical networks, delivering services to approximately 35 000 patients per network. Continuity of information has been enabled through the universal use of EMIS Web across all practices and continuity of management is delivered through a set of commissioned network-improved services.

RELATIONSHIP CONTINUITY

Recognition that relationship continuity of care (RCoC) needed priority came from: the findings of local audits in two large, high QOF-performing practices, a pilot workforce analysis in practices that are increasing in size (most practices have >6000 registered patients), and a national directive to provide patients with a named GP. The first audit described delays in cancer diagnosis, with over eight GPs on average being seen in the year before diagnosis. The second, an audit of care in the year before death in hospital, showed that patients saw up to nine different GPs. The pilot workforce analysis revealed that most of the 300 GPs in Tower Hamlets are working in a part-time capacity and that >70% are working as sessional GPs.²

BENEFITS OF MICRO-TEAMS

As part of a drive to improve quality of care in general practice, the clinical commissioning group invited practices to participate in a pilot to establish micro-teams as a novel way of both restoring RCoC and to trial working more collaboratively within general practice.³ Micro-teams offer the opportunity for peer review of complex cases and improved safety through a second opinion. They also have the potential for providing emotional support for staff, moving away from the solitary working characterising smaller single-handed practices.

Five large practices (with 9964–12 485 registered patients) responded in June 2014. One of the practices had already established a ‘buddy’ system but wished to develop this further. Practices were free to define their own team model and could include a range of professionals with different skills, such as the GP, nurse, healthcare assistant, social care worker, and patient advocate, or other professionals. They were also able to define whether to allocate all patients into teams or to focus on a particular cohort of patients.

At baseline, all the practices were asked to complete a survey assessing levels of personal achievement and to survey a sample of patients who were to be allocated into teams. Results showed high levels of patient satisfaction as well as a sense of personal achievement among staff, suggesting that higher-functioning practices have selected themselves for this pilot.

Four of the five practices have decided to focus on a specific cohort of patients with complex needs identified for the enhanced service specification for avoiding unplanned admissions. The fifth practice, with a long-standing established commitment to a named GP, wished to consolidate its system.

Clinical leads have been identified at each practice and overall leadership is being supported by the Tower Hamlets GP Care Group (a federation of all practices). Qualitative interviews will be conducted at each practice to monitor progress until November 2015.

Anecdotal evidence already suggests that micro-teams can bring back the best aspects of small practice working, but under the protective administrative umbrella of being part of a larger team and a newly established GP federation comprising all of Tower Hamlets’ practices.