• Run by One Care, a GP-led organisation that represents and supports practices in Bristol, North Somerset and South Gloucestershire.
  • Aiming to improve continuity through interpersonal care between a patient and single health care professional (or micro-team) for all appointment types across GP practices, leading to better personalised care for patients and improved job satisfaction for staff.
  • Introducing team-based models of primary care in which micro-teams take responsibility for a group of patients and share their care.
  • Running for two years from January 2019.

Modern GP practices are focused on extending access to care beyond traditional core hours and finding innovative ways of working at scale. However, this can impact on continuity of care and result in less people being able to see a specific GP.

This project from One Care intends to redress this balance across GP practices in Bristol, North Somerset and South Gloucestershire, with the aim of reaching a practice population of 400,000 patients. The project will focus on improving continuity by increasing the number of patients that see the same health professional or small team over a period of time.

The project team will work with interested practices to develop a bespoke toolkit (including a digital toolset, delivery model, training programmes and patient materials) that offers two approaches to delivering more effective relational continuity of care.

The first approach will create practice micro-teams led by ‘clinical champions’ that look after specific groups of patients (for example, frequent attenders or people who are housebound). The second will introduce personalised micro-teams for all patients to include a named clinical lead, one or two GPs, and nursing, pharmacy and administrative support as needed.

One Care will work closely with patients and practices to establish their needs and identify vulnerable groups that will benefit the most from improved continuity of care. 

As well as improving personalised care and patient satisfaction across all appointment types (face-to-face, telephone and home visits), better continuity of care is expected to lead to improved staff confidence, efficiency and job satisfaction through improved engagement with patients.

Contact details

For more information, please email Ruth Hughes, Development Consultant at One Care.

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