Some patients may have complex needs. In order to help you understand if this service would be suitable for you, we have provided a few examples of imaginary patients below. We would always encourage you to call and speak with us before registering if you have any questions or wonder whether this service would meet your needs.
Miss M is a 23 year old lady living in south east London who becomes pregnant whilst registered with the service.
The NHS advises that all pregnant women are registered with a GP Practice close to where they live, so that care can be co-ordinated between midwives and other antenatal and postnatal services locally. As a result, we would work with Miss M to decide where she wishes to have her baby, arrange a referral to the appropriate antenatal services, and discuss the advantages of registering with an alternative GP practice in her home area if necessary.
Mr M is 45 year old man living in Lambeth with a history of schizophrenia whose mental health starts to deteriorate.
We would work with the Community Mental Health Team in Lambeth to agree an assessment and treatment plan. This may involve Mr M being registered with a practice closer to his home, and in which case we will work with him to arrange this in a careful way with full handover to his new GP. Equally, the rapid access to a GP provided by our service may be very beneficial for Mr M, and it may be appropriate for him to continue to be registered with us with backup from his local Mental Health Team. We would carefully consider the best option with Mr M, and arrange regular review, or when there is any change in his condition.
Miss E is a 3 year old girl attending with her mother with a with recurrent infection and some concerns about her behaviour at nursery.
We take the safety and wellbeing of all our patients very seriously, particularly children and vulnerable adults. If there are any behavioural or other concerns of this type highlighted during a consultation, the Safeguarding Lead is alerted and will ensure that appropriate follow up is arranged to ensure the child’s safety.
Mrs H is a 73 year old patient with a diagnosis of terminal chest disease who lives alone. She has just been discharged from hospital much less mobile than she was previously and needs regular dressing changes to a wound on her leg.
As soon as the hospital lets us know that Mrs H has been discharged, one of our GPs will call her to discuss what referrals have been made and what needs to be arranged. The GP will ensure that all referrals are made to the appropriate District Nursing and other community teams. Our Complex Care Co-ordinator would make sure that these referrals are followed up and Mrs H’s care is arranged as planned.
We would also have a conversation with Mrs H about the pros and cons of remaining registered as an out of area patient or whether she would be better to transfer to a practice closer to their home. If she decided to register locally, we would work with her to ensure a safe and efficient transfer of care.
Ms L is a 48 year old woman who has been discharged from hospital following a stroke. She takes blood thinning medication and lives in Merton
As soon as the hospital lets us know that Ms L has been discharged, one of our GPs will call her to discuss what referrals have been made and what needs to be arranged. The GP will ensure that all referrals are made to the appropriate District Nursing and other community teams. Our Complex Care Co-ordinator would make sure that these referrals are followed up and Ms L’s care is arranged as planned.
Arrangements for monitoring her blood thinning treatment would also be discussed. Regular blood tests would be needed, and she will need to be referred to a hospital anticoagulation clinic to have these done. Ms L could then request repeat prescriptions for her medication from us.
We would also have a conversation with Ms L about the pros and cons of remaining registered as an out of area patient or whether she would be better to transfer to a practice closer to their home. If she decided to register locally, we would work with her to ensure a safe and efficient transfer of care.
Miss Z is a 28 year old woman who previously had an abnormal smear test and is having them done yearly for now. She missed her most recent test.
When a woman of smear age registers with us, we check that they have had a smear recently. If they haven’t, our administrator would call someone like Miss Z and offer her an appointment at one of our physical location to have a smear test taken.
Mr J is a 74 year old gentleman with early dementia. His District Nurse is concerned that he might be becoming more confused.
When the district nurse calls us, we would make sure that a GP is available to talk to them. We would try to arrange a home visit for Mr J if at all possible. Call would be taken by a clinician who would then arrange a home visit for the patient. Depending upon the outcome of this visit, referrals would be made, and community care arranged by our Complex Care Team.
It would probably be appropriate for Mr J to be registered with a practice closer to his home, as a confused patient may not be able to book digital appointments. This would be discussed with Mr J and his carers, and if appropriate, a well-managed transfer of care to a local practice would be facilitated.
Mr F is 57 year old man living in Wandsworth with possible learning difficulties. He needs repeated prescriptions for strong painkillers for his back pain.
Following a digital appointment, we would arrange a face to face appointment for Mr F to assess both his back and his need for ongoing painkillers. Many strong painkillers are “controlled drugs” that require particular handling and have additional safeguards around prescribing. All prescriptions for long term controlled drugs are carefully considered in a face to face appointment before being issued. If appropriate, ongoing prescriptions can then be issued following a digital appointment up until the agreed review date.
Homeless persons, sex workers and other marginalised groups
Currently these groups are recognised as receiving poor care from conventional NHS services. Given the access to digital appointments and multiple clinical locations, such groups will benefit to a great extent from this service.