Community Network

Community services support named GP role in Suffolk

older woman and care worker

25 / 11 / 2014


Suffolk Community Healthcare is working with ten GP practices to pilot an extensive role for named community matrons in supporting the named GP role in coordinating care for frail older people.

What the organisation is doing

  • Each community matron partners with one to two GP surgeries and patients are identified using the RaidR risk stratification tool. Matrons manage their patients using shared care plans with named GPs, supporting the ‘named GP’ challenge.  
  • Matrons work with surgeries using System One, an agreed template to integrate and share data.
  • The matron and community service acts as the initial point of contact  for the patient, rather than the GP surgery.
  • The initiative draws on earlier joint work on a similar model which demonstrated financial savings and improved patient experience.

Results and benefits

  • Reductions in hospital admissions and unscheduled GP visits, and perceptions of improved care and wellness (patient experience captured via a patient survey and the friends and family test).
  • Expected benefits include supporting people to self-manage, encouraging people to access alternatives to A&E out of hours, reducing avoidable hospital admissions and  earlier engagement of appropriate agencies.
  • Challenging to ensure all relevant stakeholders aware of this alternative to A&E.
  • The model builds on past learning, but a key difference is that it is far more systematic in measuring and demonstrating achieved outcomes.

    The project hopes to provide evidence that it has helped manage the growing demand on GPs, reduce hospital admissions and improve patient experience, through highly skilled practitioners (community matrons) working alongside GP practices to develop a ‘single point of access’ service for highly vulnerable patients.  
  • The model and its outcomes are expected to influence the clinical commissioning group's (CCG) approach to engaging the community matron services, particularly as it aligns with and helps to address the CCG’s priorities.

What to know more?

Please contact Julie Gaughan, project manager, NAPC:

The case study is taken from Working better together: community health and primary care.

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