Over 1300 vulnerable people in Sheffield have so far benefited from a new service set up by a group of GP practices and funded by NHS Sheffield Clinical Commissioning Group (CCG).

The Sheffield GP practices who make up the Sevenhills Primary Care Network set up the new home visiting service in response to the Covid-19 pandemic so that vulnerable and frail people who may not be seeking help as they normally would can be seen and don’t have to come into the GP practice.

Sevenhills Primary Care Network is made up of a group of 5 GP practices covering Darnall, Tinsley and Handsworth including two practices managed by Primary Care Sheffield, and during Covid-19 has been joined by Primary Care Sheffield’s five additional practices across the city. They cover a total patient population of 47,000 people.

By working together the practices can provide more personalised and coordinated health and social care, supporting people to gain control of their health and wellbeing, helping them to live well and independently as well as reducing ill health and unnecessary hospital admissions.

Over 1300 vulnerable people have now been seen since the service was set up with 150 patients seen in the first 5 days of the service running in June.

As part of the visits, patients with long term conditions such as diabetes, heart disease and chronic obstructive pulmonary disease can be safely seen at home by a healthcare assistant for their review and check-up rather than having to come into the practice like they usually would before Covid-19. The visits are also helping to tackle isolation and vulnerability.

Patients will have tests depending on their condition, such as bloods, urine, blood pressure, heart rate, weight and foot checks. They are also asked what their biggest worry is to identify any unknown clinical and social issues that they could receive help with.

After the visits, the results are reviewed by a GP and they have a remote consultation with a practice nurse over the phone to talk through the results. The practice nurse can then refer them to the relevant people such as a pharmacist for a medicine review, a GP, physiotherapist or link worker depending on their needs.

Dr Lucy Cormack, Clinical Director for the Sevenhills Primary Care Network and Primary Care Sheffield practices, said, “The home visiting service is making a massive difference to patients in the area. Just some of the examples of people we’ve been able to help are a 90 year old diabetic who thought they were okay but actually turned out to need an urgent GP appointment due to some worrying symptoms and an 80 year old diabetic whose blood sugar has drastically improved since being seen.

We have also seen and been able to help people who are struggling to buy food, people worried about their memory, weight gain and people dealing with pain or not able to get around the house.”

A patient treated through the service, said: “As a patient with multiple illnesses and who was shielding in this COVID 19 Pandemic I found the service provided by my doctor’s surgery and our Primary Care Network extremely helpful and reassuring.

“I did not feel isolated or neglected.  My doctor’s surgery made regular courtesy telephone calls to enquire if I was alright or needed any help. “

NHS Sheffield CCG gave the Sevenhills Primary Care Network £32K of funding to support their response to Covid-19. The service will run for an initial three-month period but there are plans to continue the service as long as the patient need continues.

Dr Zak McMurray, GP and Medical Director at NHS Sheffield CCG said, “It is great to see so many people benefitting from this new home visiting service during the pandemic. One of the benefits of GP practices working together as Primary Care Networks is that they can develop services locally in response to the needs of the patients in their particular areas. The home visiting service has been so successful that other Primary Care Networks across the city are now looking at developing similar services in their areas.”

Since the beginning of the Covid-19 outbreak GP practices have been responding to the crisis and working hard to ensure patients, particularly those who are vulnerable, get the care they need. As a result of Covid-19 there are many new ways care is now being delivered and this service is just one of several initiatives that will appear as we enter the ‘new normal’ for primary care.