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Moatfield Surgery – a more personalised care approach – our complex care team – creating a win:win

For a number of years, we’ve observed growing challenges familiar to everyone in primary care. The rapidly growing number of people needing support for their long term physical and mental conditions, their personal circumstances and the impact on their conditions and lives, the challenge of meeting demand which in part is a numbers game when it comes to the logistics of ‘delivery of care’ but is more meaningfully about the values of a team, how a team is constructed – the breadth, the quality and the dynamics, how it evolves a number of approaches – quality improvement, learning process, confidence. It is definitely also about how we use our existing and emerging technology to its fullest.

Over the last three to four years, the daily team huddles incorporating downtime, discussion about quality improvement ideas from all parts of every team with a clear structure management structure with rolling plans and identified accountabilities for making stuff happen has helped us to create a culture and environment for us to continually improve. In that time, we introduced dedicated GP led mental health clinics, group consultations for people with long term conditions to virtual groups during the pandemic amongst many changes that will be familiar to general practice across the country. Arguably the fastest changes have occurred since the pandemic struck.

Within the first week our website had been dramatically changed to provide the latest COVID-19 information to our community but, as importantly if not more so, we changed and published all our long-term care pathways for our patients, incorporating remote care within that time and made our patients aware. But to minimise the risk of digital exclusion, we contacted all our patients (and their carers) with known sensory impairments and learning disabilities to agree what was the best method for each person to communicate with us and vice versa.

Like many practices, over the years, we have evolved our register, recall and care processes for people with long-term conditions whether these are within the quality and outcomes framework or not. Previously the pace of change we wanted was blunted by limitations in team capacity and individual skills and experience.

Building our complex care team and a more personalised approach.

Commitment to two main objectives:

1) Improve effectiveness of recall processes to minimise patient attendances for multiple condition-based management. We have segmented our population differently to identify those most at need and those with similar needs which is the essence of a population-based health approach. We have used this data to profile how we meet these needs over a year so that, for example, reviews that might be more logically carried out before autumn are undertaken earlier in the year. We have attempted turn around the notion of one person, many conditions and many health-based appointments to one person, health, wellbeing and social needs, the right professionals contributing to support
2) Offer holistic personalised care, disease management and effective signposting where needed and prioritise those who need it the most – attempt to address inequalities and improve population health
• We hope to engage other partners and new additional roles recruitment scheme (ARRS) roles around occupational therapy
• Work with partner organisations such as East Grinstead Town Council, MSDC (coaching and wellbeing)

The team:

  1. We were able to bring a very good pharmacist into the team with a focus on improving care for people with long-term needs as well as more medicines management. Subsequently via the PCN based ARRS scheme, we have a second excellent pharmacist to support the work.
  2. Capacity and skills were further enhanced through ongoing training across our team of nurse practitioner, nurses, HCAs, pharmacists, GP lead, care coordinators, social prescribing link worker and phlebotomists. They work together, huddle together and learn together!
  3. We also brought onboard two great first contact physiotherapists with a focus on people with chronic pain as we know from our data that this group of people usually do not have their needs met well and are in the top five groups of high users of general practice as well as other services.
  4. We are in the process of bringing onboard an employed wellbeing coach, working with our local wellbeing hub to do this.

Personalising the care

  • Identifying those at most need of early support or intervention through a complex recall process we have designed ourselves using EMIS, capturing disease data, calendar-based recall, disease markers and other risk-guiding information such as ethnicity. The recall process has been designed and executed by a trained team to minimise the number of appointments people are called for including the minimisation of multiple blood tests where, for example, they may need blood tests more than once a year.
  • This process has crucially enabled us to identify people who will manage well with more remoted based support and digital tools currently available to us and our patients eg MyDiabetes, our website based resources ( We are in the process of introducing the Omron remote hypertension management tool as I write.
  • Initial remote contact either by text or email or by our group consultation coordinator for information from the person for background lifestyle and other disease information where they are able to provide this but also to identify people who may struggle with more remote care approaches.
  • Then an initial health care assistant (HCA) appointment for a first assessment (eg weight, BP), blood tests and initial lifestyle intervention and starting the care planning process with the patient and/or their carer
  • This is followed by a desktop review involving combinations of a nurse practitioner, pharmacist and supporting GP looking at possible biopsychosocial needs. This process may also involve the chronic pain physiotherapists, social prescribing link worker and care coordinators. We have access to a geriatrician and hope to resurrect the link to IAPT lost at the beginning of the pandemic.
  • The desktop review may result in a number of actions for the person (and their carer) including a single extended complex care review, group consultations, coaching or physiotherapy intervention, consultation with usual GP, pharmacist medication review and the further development of a personalised care plan (already established), use of existing self-support tools and apps
  • We identify people who may benefit from virtual multidisciplinary team (MDT) discussions with the geriatrician, community matron and palliative care team.
  • We take feedback from the patients involved and their carers to identify how we might improve on what ware doing. Feedback so far has been overwhelmingly positive.

We initially developed this way of working with people with four or more long-term conditions as our data indicated that this would capture some of the groups of patients with the top five underlying factors driving general practice demand (namely anxiety, obesity, frailty, chronic respiratory disease and chronic pain).

We have now expanded this approach to much wider range of our patients as we have built the capacity, knowledge, skills and confidence in this approach. This is an ongoing reasonably intensive approach to improving care and support for people with ongoing needs. We have been fortunate to have driven team members, a great clinical and management structure with a clear plan and accountabilities as well as excellent IT skills amongst our management and clinical team to make things happen. We’ve spent time and money on training and upskilling and enhancing pay where needed as well as expenditure on digital resources.

We believe that the rewards will be more efficient and more personalised and effective care, being able to meet demand in a way that we believe a traditional approach will no longer work and important to the quality of care we provide, happier team members who feel more in control of their work.