Multi-specialty Community Provider | Wandsworth GP Federation

The Multi-specialty Community Provider ( MCP ) model combines delivery of primary care and community based health and care services as well as incorporating a much wider range of services and specialists wherever that is the best thing to do. This could mean mental health as well as physical health services, and potentially social care provision. The model facilitates care closer to home and focuses on a 'place-based' model of care.

In 2017, Wandsworth GP Federation (previously BHCIC ) was appointed lead provider of the MCP model for Wandsworth. This means we work together with other organisations to provide services for people in the community such as community nursing, community rehabilitation, discharge from hospital support and end of life care support. We oversee the way services are provided and ensure the services meet the needs of the population of Wandsworth offering timely, effective and safe care for patients.

Diagnostics

Buying equipment for GP practices in Wandsworth so that patients have a wider range of services such as:

in-house spirometry
24 ABPM
ECG
Phlebotomy

Enhanced Care Pathway

When a person is vulnerable to sudden deterioration and emergency hospital admission they are added to the Enhanced Care Pathway ( ECP ). ECP patients receive care and treatment from their GP practice and other community services such as district nurses and social services.

The ECP includes Rapid Response Services and Medicines Usage Reviews.

A Medicines Usage Review ( MUR ) is a service provided through a local contract with a Wandsworth Pharmacy (Pearl Pharmacy in Tooting) and local pharmacists within practices. It's an annual review for people who take multiple medicines and particularly those receiving medicines for long-term conditions to check everything is still ok and gives people the opportunity to ask any questions they may have about the medicines they are taking.

Improving access to primary care

8-8 Access

Patients in Wandsworth can book routine appointments with their GP practice in the evenings and weekends at three Wandsworth 8-8 hubs.

Planning All Care Together (PACT)

PACT is an initiative developed by the CCG allowing practices to offer extended appointments for vulnerable patients and carers.

Quality improvement in primary care

We are always looking for ways to make improvements to the quality of the care that is provided to patients in Wandsworth. Working collaboratively with the GP practices, Primary care Networks and Clinical Commissioning Group, we deliver a model of quality improvement for primary care services. This means making sure that the practices have the right expertise and support to develop and improve their services, ensuring the ongoing delivery of high-quality care. This is achieved through facilitating the practices to work together, offering peer support opportunities, shared learning and reviewing areas of practice to promote best practice.

Regular events are run for the practices to offer education and development opportunities focusing on areas of quality Improvement that are identified through practice reviews, service user feedback, introduction of new clinical guidance, local and national health policy changes – all contribute to a culture of improvement and best practice.

Supporting people with learning difficulties

We work with Generate to ensure people with learning difficulties are supported to attend important health check appointments.

Age UK Wandsworth

We work with Age UK Wandsworth to deliver their Better At Home services for people aged 60 or over, or their carers.

Age UK Wandsworth offers lots of services (for older people and their carers) that can help promote independence, support people coming home from a hospital stay and provide help and advice.

Central London Community Healthcare

We work with Central London Community Healthcare NHS Trust to deliver Community Adult Health Services in Wandsworth.

CLCH provide community health services predominantly for housebound adults within Wandsworth such as community nursing, community therapy rehabilitation and complex case management. CLCH also provides range of community based specialist nursing services e.g. Diabetes specialist nurses who work closely with the GP practices to deliver specialist diabetes care closer to home for patients.

Lymphoedema

We work with Accelerate to provide CLCH 's Community Nursing Services with specialist lymphoedema support and advice for housebound patients who need wound and lymphoedema care.

Support for Care Homes

As part of the national programme of Enhancing Health in Care Homes we work with a number of organisations to offer care homes in Wandsworth in-reach services providing specialist advice and support to the care homes to enable them to better support the health needs of their resident.

Central London Community Healthcare's Community Adult Health Services provides Advanced Nurse Practitioner support.

St George's Hospital provides Dietetic, Occupational Therapy and Physiotherapy support and Royal Trinity Hospice provides specialist end of life care support.

Wandsworth End of Life Care Coordination Service

We work with the Royal Trinity Hospice to deliver the Wandsworth Care Coordination Service to provide support and coordination of care for people approaching the end of their lives, and their carers, in order to support them to remain at home if this is their wish.

Marie Curie

We work with Marie Curie coordinated through the Wandsworth End of Life Care Coordination Service to offer overnight care to support people with end of life care needs, allowing more people to remain at home at the end of their lives if that is their preferred wish.

MICAS

MICAS is delivered by BHCIC while the other services in the Wandsworth MSK pathway are run by St George’s Hospital. St George’s Hospital is the local hospital providing a wide range of specialist, outpatient, acute and general hospital services to South London.

Patients can still be seen at other hospitals if they’ve specified this choice on their referral form.

More about MICAS

MSK Single Point of Access

MSK services in Wandsworth are provided through an alliance with St George’s Hospital. When referrals are sent to the MSK Single Point Of Access ( SPOA ) they are clinically reviewed by a team of clinicians employed by St Georges Hospital.

BHCIC delivers the administrative element of the SPOA . Patients can call the team for information or updates about their appointments.