Transforming Primary Care Service Delivery in Forfar

Questions to the doctors

GPs from Academy & Ravenswood medical practices are merging to form the largest practice in Tayside (14,126 patients) to transform the service for the patients in their community.

Why did you decide to merge?

We recognise that a different approach is needed in order to improve access, health & wellbeing, and offer sustainability for the future, we have engaged our patients and staff in designing and delivering a new model of primary care that is informed by the Alaskan Nuka system (name given to the whole health care system created, managed and owned by native Alaskians to achieve physical, mental, emotional and spiritual wellness – putting relationships at the forefront.   

So what is the aim?

We want to ensure that patients are seen in the right place at the right time by the right person.

Through this new way of working we want to ensure that our patients are empowered to self manage and self care and that patient experience and outcomes are positive.

It is also important to us that our staff experience and engagement is positive while ensuring that surgery resource are used effectively, is profitable and sustainable for the future.

Tell us a bit more………

Our Model

Six small co-located integrated teams will each look after a defined population of around 2,400 patients.  In phase one, team members will include 1.5 GPs, a nurse, a healthcare assistant, an administrator and named community nursing staff.  In phase two, we hope to introduce a behavioural psychologist.  Team collocation means that the team is fully integrated and care coordination is maximised.

The model offers a biopsychosocial model of health, where all the patient’s health & wellness issues are addressed at the time they attend, reducing the need for return visits to the surgery and improving patient outcomes.

A model of care & support planning is used in helping patients self manage and thrive.  This way of working offers a model of relationship-continuity and partnering with patients which builds trust and confidence between patients and professionals.

In optimising relationship-continuity, our model offers a patient-centred, biopsychosocial model of care intended to improve health outcomes and reduce health inequalities.

Action Taken

In six months, we have already created the conditions for change.  Working collaboratively with patients and staff, we have:

  • Achieved “buy-in” to our initiative and inspired proactive engagement.
  • Designed our model and created 6 small multidisciplinary teams.
  • Defined the model’s care & support planning approach.
  • Asked patients to select their team of choice.
  • Begun clinical training in case management, health behaviour change, long-term conditions management and relational approaches.
  • Begun negotiations with community nursing, psychology, local authority and 3rd sector partners.
  • Planned our premises and IT infrastructure.
  • Begun reviewing patient flow, clinical protocols and administrative procedures.
  • Obtained project management support.
  • Held shared learning events.
  • Begun baseline evaluation of a range of outcomes measures.

Lessons Learned

  • Having dedicated clinical and project management leadership is essential in developing and supporting the initiative and enabling the work to gather pace.
  • Innovative vision is created through an understanding of the difference between sustaining innovation geared to maintaining the current system in a more efficient form and biased towards the past, and forward-looking transformative innovation that paves the way for a new system that fits better with the changing world and emerging need. (International Futures Forum)
  • It is possible to adopt the best of innovative and radical new models that may seem unrealistic in our current system and adapt these effectively to local need.
  • Culture must be developed intentionally alongside practical considerations in order to embed a new way of “doing business around here”.
  • All activity must be aligned to achieving vision.

Next Steps

In the next six months, we will complete and embed the work we have begun and, in collaboration with patients and staff, we will explore relevant health, social and 3rd sector partnerships and pathways with a view to delivering a comprehensive & coordinated service.

The launch of our new model is planned for early 2016.

Let’s hear Dr Andrew Thomson speak first hand about this new model:


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