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Primary care improvement for patients with complex long-term conditions

Patients with five or more long-term conditions have been shown in Barking, Havering and Redbridge Clinical Commissioning Groups to be the heaviest users of health and social care. An innovative new model of primary care, ‘Health 1000’ was thus established. Comprising a fully integrated multidisciplinary team (including third sector, a social worker and dual skilled ‘keyworkers’) this practice aligned the care of complex patients and endeavoured to avoid unnecessary hospital admissions.To test the hypothesis that Health 1000 (a multidisciplinary GP practice with consultant geriatrician support) would align and improve quality of care and health/social outcomes for complex patients with five-plus long-term conditions.Using anonymised disease registers, an eligible cohort was identified and invited by their existing practices to re-register with Health 1000. Each patient received comprehensive initial consultation at registration, encompassing reviews of pill burden and social need. Biweekly multidisciplinary discussion ensured their care was aligned and met to a high quality. Independent qualitative evaluation was undertaken by the Nuffield Trust using face to face/telephone interviews with staff/patients.408 patients (from an eligible cohort of approximately 2000) were registered. Most patients were extremely satisfied with the new service highlighting friendly welcoming atmosphere, speed of service, key workers’ responsiveness, availability of phone consultations with GPs, longer appointment slots and home visits.Qualitative outcomes were very positive and suggest that there is benefit for patients with multiple long-term conditions from embedding a multidisciplinary team in primary care with specialist expertise.