Community matrons can save money and improve care - and Nina Barnett and colleagues have the evidence to prove it

As part of its ongoing workforce reform, Harrow primary care trust decided to explore the community matron role through a pilot supervised by a steering group from health, social care and clinical governance.

It recruited two matrons in December 2005 who were then trained and accredited in advanced clinical skills as well as being assigned mentors.

In the first three months of the pilot, the trusts identified GP practices that wanted to support its objectives and help in the accurate identification of high-risk patients, particularly vulnerable older people. To identify the target group of patients - known as very high intensity users (VHIUs) - the Department of Health's 'patients at risk of readmission' (PARR) tool was used in conjunction with other data.

Moving on to case management of the identified group, most of whom had more than one condition, the matrons identified key issues affecting the patients' conditions, such as medication. Efficient medication management is known to help to save money and prevent morbidity for vulnerable patients. Key clinical interventions made significant differences to patients' lives and reduced the number of GP visits.

Community matrons are required to use a whole-systems approach, including the single assessment process, to implement and co-ordinate services for VHIUs across health and social care.

The extent of direct involvement from the community matrons varied according to case complexity. In some instances, they were able to support existing case managers with guidance, with referral to the matrons for assessment and crisis intervention only. In others, the patients were directly managed by the community matrons.

The pilot project indicated that a relatively small number of patients had such complex needs that community matrons needed to manage them directly. It also highlighted the importance of the ongoing leadership the role can offer to case managers through supervision and review.

GPs involved in the pilot recognised that admissions had been avoided and reported a reduction in requests for visits from patients being managed by the community matrons.

A GP mentor highlighted the benefits of the advanced training and proactive case management. All GP practices saw immediate benefits from community matrons in prescribing and care plans.

The pilot work highlighted the importance of clear communication. It also emphasised the need for shared health information to help with clinical governance. It was clear that record keeping had to remain centred on GP systems, although this could change when fully integrated electronic care records become available.

Some staff commented on the improved communication between health and social care as a result of community matron involvement, especially in continuity of care.

The community matrons, GP mentor and steering group all stressed that mentoring and support was crucial. The biggest challenge for the pilot matrons was to establish their place in current health and social care services. It was clear that failure to integrate the roles into the community and primary care would result in ineffective, unco-ordinated patient care.

This pilot suggests that community matrons can make a positive difference to vulnerable patients. An autonomous and advanced nurse practitioner and prescriber in primary care managing a defined caseload of high-risk patients can help patients and reduce care costs for the PCT.

In a wider context, it has highlighted the need for service redesign. Nursing care in the community is taking on a new perspective in the changing NHS, and the community matron role can provide both the co-ordination and supervision needed to develop an existing but often fragmented service.

Nina Barnett is a specialist pharmacist for older people at Harrow PCT, pharmacist prescriber for the Denham Unit nursing home and pharmacy adviser for older people for London, Eastern and South East Specialist Pharmacy Services; Dr Chris Jenner is an honorary senior lecturer at Imperial College London, older people's lead for Harrow PCT and a GP; Heather Baker is head of primary care nursing at Harrow PCT.