• Run by Pier Health, a GP provider for the Weston-Super-Mare and Worle areas of North Somerset.
  • Aiming to improve continuity of care and reduce variations across nine GP practices, leading to reduced workload, and improvements in patient and staff satisfaction.
  • Helping patients to develop a therapeutic relationship with their preferred clinician by introducing micro-teams and implementing systems that match clinical capacity to demand.
  • The project will run from January 2019 to December 2020.

Continuity of care has been shown to have many benefits and, along with accessibility, is a core attribute of primary care.

However, GP practices across the Weston-Super-Mare and Worle areas of North Somerset have major problems with low levels of continuity, high workloads and wide variation in access and continuity rates across the patient populations they serve.

Pier Health believe that good access enables continuity to be offered and high levels of continuity reduce demand and make access easier. This project aims to demonstrate that it is possible to increase continuity of care by helping all patients to develop a therapeutic relationship with their preferred clinician in a community of nine general practices.

The first phase will involve an intensive support site programme that enables practices to match clinical capacity to demand with the help of a digital access tool, focusing on doing today’s work today, rather than separating urgent and non-urgent cases.

The second phase will increase continuity of care across all practices through the five key processes of engaging, measuring, matching, enabling and enhancing. Micro-teams that include each patient’s preferred clinician, supported by another GP, nurse or advanced practitioner, will work together to cover the working week and manage a list of patients.

An implementation team will work in each practice to support the extra work involved and ensure it is fully embedded into systems and culture.

The project team hope to double continuity levels within two years, reduce inequalities between practices, and demonstrate significant improvements in patient and staff satisfaction. They also anticipate a 5–10% reduction in clinical workload and less need to use wider services, such as accident and emergency, and out-of-hours clinics.

Contact details

for more information, please email Kevin Haggerty, General Practitioner at Pier Health.

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