Milton surgery in south-east Edinburgh is a six partner training practice with a patient population of 8,000. The site was approved as a personal medical services pilot for three years from April 1998.
Established under the 1997 NHS (Primary Care) Act the pilots are intended to provide flexible services better attuned to local needs. As well as improving the quality and accessibility of services, they set out to tackle the unmet needs of specific groups of people, and improve the recruitment and retention of clinical staff.
This has involved quite significant changes in the organisation of the practice.
Moving from general medical services to personal medical services gave the surgery the opportunity to draw up a new locally agreed contract between the practice and Lothian health board. The practice registered as an NHS body, and a prerequisite to this was that all partners resigned their medical lists. In essence this means that the practice now holds the same status as a trust. The concept may be attractive to Scottish local healthcare co-operatives wishing to increase their autonomy: it gives the opportunity to establish a contract with the primary care trust which encompasses all the services provided in a locality.
The contracting process included negotiating an annual budget. This was calculated on historical data for general medical services, supplemented by£71,000 from Lothian health board to employ a salaried GP for nine sessions and a part-time project manager. New arrangements have removed the need for item-of-service claim forms and paperwork transfer between the practice and health board.
As part of the scheme, the practice appointed a salaried GP to make the necessary time for partners to provide additional 20-minute appointment slots for patients with chronic health needs. Time is spent with patients designing care plans.
These care plans initially covered asthma, diabetes, gastro-intestinal diseases, cardiovascular problems (at risk group), polypharmacy (patients on multiple medications), cognitive impairment and epilepsy. But the scheme was set up to allow any patient with chronic health or social needs to have a care plan designed for them.
During the first year of the scheme, 1,000 care plans were initiated.
Each plan is established with regular review built in at agreed time intervals. One of the partners designed a database for the scheme. This provides a tool for audit, review and recall, recording appropriate clinical markers for each chronic disease category. As soon as a patient is logged on the database they are automatically followed up.
Each patient recruited to the scheme has a linksheet attached to their medical record summarising current health and social issues such as benefits claimed and contact with other agencies. The sheet also ensures regular review of medication and identifies procedures to be performed at specified intervals by the practice nurse, such as a standard health check or specified blood tests.
Evaluation is built into the project and has been extended by Lothian primary care trust. In addition, the site was selected as part of a national evaluation programme undertaken by Southampton University looking at quality of care.
Evaluation will determine whether the concept is viable and can be adapted on a permanent basis.
The practice reports every quarter to the project board on activity, costs and consultation rates. The project board consists of the director of primary care, the contracts manager, a public health specialist, the management accountant and medical prescribing advisers from the primary care trust, and the lead GP and project manager from Milton surgery.
Patient surveys and an economic evaluation will be carried out along with an analysis of the use of secondary services before and during the pilot.
It is hoped that the new contractual arrangements will continue after the three-year period and that benefits can be shared and extended to other practices in due course.
The feedback from GPs in the practice has generally been positive. They can allocate longer appointments to patients who are likely to benefit from them. They also value being able to show, through clinical data collection, that best practice guidelines are being followed for each of the chronic disease categories.
Activity trends also suggest that the practice has reduced its use of secondary services .