Patients needing treatment for rheumatology are able to be seen quicker and avoid going to hospital thanks to a new way of working, which has received national recognition.
The Connected Health Network (CHN) model enables GPs in our area to work in partnership with specialists from Northern Lincolnshire and Goole NHS Foundation Trust (NLaG) to manage patient care within primary care where possible. Rather than referring patients to hospital, GPs access the CHN service, which is delivered within their own Primary Care Network (PCN). A rheumatology pilot with Meridian PCN was established in April 2022, aiming to embed specialist input in primary care and reduce unnecessary referrals to secondary care.
The MDT model in primary care includes:
- A GP with a special interest (rheumatology and dermatology) triaging and seeing patients in the CHN clinic
- A lead consultant joining the last part of the clinic by video call to discuss patients, advising on investigations, management and any requirements for referral to secondary care
- Direct access to physiotherapy and occupational therapy, access to DWP support team, weight loss programmes, social prescribing, mental health support and pharmacists.
It’s run by Dr Doria Bouzebra from Meridian Primary Care Network (PCN) and Dr Tim Gillott, Consultant Rheumatologist at Northern Lincolnshire and Goole NHS Foundation Trust (NLaG).
Alex Afifi, Senior Project Manager for Patient Services, said: “This is well deserved recognition for the excellent joint working efforts of Dr Bouzebra, Dr Gillott and the wider supporting team. It’s a really good example of a neighbourhood/community interface service with collaborative multidisciplinary working. Patients don’t have to attend the hospital, so it’s less stressful for the patient and they’re seen quicker. Primary care also have access to a much wider range of support services which we don’t have in secondary care.”
The service, which receives around 200 new patients a year, gets new referrals from both GPs and physios, and supports existing patients in secondary care. The vast majority of patients are managed within the service, and the referral rate from Meridian PCN to the hospital has fallen by 75 per cent.
The case study received strong approval from Professor Tim Briggs, the National Director for Clinical Improvement and Elective Recovery, and has been published on the national ‘Getting It Right First Time’ (GIRFT) workspace on the Futures collaboration platform.
The team were also shortlisted for a Health Service Journal (HSJ) award in 2024, in the ‘Primary and Community Care Innovation of the Year’ category.
A patient commented: “I was advised this was faster than going to hospital to see rheumatology, so I am grateful that this was an option as it appears this reduced the waiting time. Dr Bouzebra is a very pleasant, friendly doctor and it’s obvious she knows exactly what she’s talking about. She was very happy to assess my hypermobility and explain any findings to me. She referred me for the appropriate follow-up and advised me how to approach physiotherapy. I cannot fault her at all.”
Another patient said: “Dr Bouzebra was very professional, patient, and understanding. I can’t thank her enough for truly listening to me.”
Dr Bouzebra said: “I am thrilled our collaborative work with Dr Gillott is being recognised. This represents a significant milestone for the project. In addition to helping reduce secondary care waiting lists, we’ve achieved our initial aims of eliminating addictive drug prescribing and implementing a robust, community fibromyalgia pathway that keeps patients out of hospital settings, while providing more holistic and effective management of their condition.
“Both outcomes are measurable and evidence-based, and they form part of a broader set of achievements. The service also has considerable potential to deliver even more efficient and cost-effective care, if given the opportunity to develop further.
“This service has been a valuable support to primary care and the practice where I work. It has played a key role in offloading complex patient cases, allowing clinicians to focus on other priorities, while also enhancing patient education.”
Dr Gillott said: “Dr Bouzebra and myself have been running the Connected Health Network Rheumatology service for nearly four years now. It’s wonderful the hard work of ourselves, our supporting staff and management team is being recognised by the publication of our GIRFT case study.” “We hope it will stand testament to the benefits of such a coordinated approach between primary and secondary care.”