care staff working service GPs areas area patient attached nurses caseload district social patients buurtzorg geographical model team system works advanced community capacity integrated management practice nurse nursing support skills relationships DNs workload virtual demand experience feel great complete role sounds needed key tool complex improve frontline encourages awareness outcomes prevent making meet sharing raise band agree improved HSCIC Glasgow worked units health decision advise adv communication contact continuity challenging build regular resources review rural travelling share managed managing issue pressure practices prescribing looked similar solutions trained today teams systems surgeries shift report pts rarely city clinical challenge daily basis big boundaries bring access due encourage highlighted future integration increased visits unique understood urban unclear yeah increasing interesting improvement impacts important gap guidance evidence Encouraging ensure Ensuring education diverse deliver ACP advancing adds analysis aware bands approach assessment days criteria covering constantly correct complexity competences colleagues choice close capture benefit