Whitewater Loddon Primary Care Network Dr Tim Cooper GP Partner, Chineham Medical Practice Clinical Director, WWL PCN
This evening ○ What are primary care networks (PCN)? ○ Who is part of the Whitewater Loddon PCN? ○ What things are happening already? ○ How will it affect me? ○ How you can help us shape the future?
What are Primary Care Networks?
“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”
What are Primary Care Networks going to do? Provide more care out of hospital and closer to home Provide more comprehensive and integrated services - to match higher levels of demand and support higher levels of self care Provide services that can better meet demand at the time of access Provide different care models to different care groups
Patient centred Hospital Specialists not diseased O Community Care V r g o a l u centred care n i n s t a a t r i y o Patient n s e c S i t o c c a i r a P l l C a r a e r n e e G
Who is part of the Whitewater Loddon primary care network?
Our GP Practices: ● Whitewater Health (Hook and Hartley Wintney) ● Clift Surgery (Bramley) ● Chineham Medical Practice (Chineham)
GP GP GP GP
Whitewater Health - 17523 Network Size Clift Surgery - 6965 38038 people Chineham Medical Practice - 13550
Who else could be part of our network? Acute hospital trusts - Hampshire Hospitals Foundation Trust Community Hospital and Mental Health Trusts - Southern Health Local pharmacies and dentists Voluntary sector organisations e.g Citizens advice, MIND Local Community groups e.g running groups Social Care - Hampshire County Council Education - local schools
What are the benefits to being a primary care network?
Benefits ● Seeing the right person for the problem you face ● National support ● Sustainability ● Share good practice and training ● Improve patient experience and outcomes ● Prepare us for the future of integrated care
How will it affect me?
● New staff to help manage problems ● New ways of accessing health care and information ● Different ways of submitting your own health data and reviewing your medication ● Support in the community ● Focus on keeping you well
New staff to support networks ● Clinical pharmacists - 2019 ● Social prescribers - 2019 ● First contact physiotherapists - 2021 onwards ● Physicians associates - 2021 onwards ● Paramedics - 2021 onwards
What things are happening already in Whitewater Loddon?
Whitewater Health Healthy Weight Project Dr Charlotte Hutchings (Whitewater) and Annette Rushmere (Whitewater PPG)
Whitewater Health Healthy Weight Project Project group : ● PPG members Public Health specialist ● ● Health Policy Manager ● Communications CCG Lead GP’s ● Working with practice manager Developed action plan with timescales
Whitewater Health Healthy Weight Project ● Displays in both surgeries Next steps ● PPG to visit local groups / nurseries playgroups/ schools etc ● Texting messages from surgery ● Evaluation of project
Whitewater Health Healthy Weight Project Let’s make Whitewater Loddon patients – and that’s all of us -healthier ! Thank You
Whitewater Loddon PCN Paediatric Clinics Dr Roisin Ward (Clift Surgery)
Clinical Pharmacists Dr Chiranthi Marston (Chineham) and Marta Radakowska (Chineham and Whitewater)
General Practice Forward View ● July 2015 NHS England announced a pilot to support the development of clinical pharmacists in general practice 10 Year Forward View Grow and develop workforce-support practices to redesign their services ● to patients ● Streamline workload ● Channel Investment and improve infrastructure Committed to over £100m of investment to support an extra 1500 clinical ● pharmacists in general practice by 2020/21.
NHS England-role of the clinical pharmacist “ Clinical pharmacists will work in GP as part of a multidisciplinary team in a patient facing role to clinically assess and treat patients using their expert knowledge of medicines for specific disease areas. The will work alongside the GP team, taking responsibility for patients with chronic diseases and undertaking clinical medication reviews to proactively manage patients with complex polypharmacy, especially for the elderly people in care homes and those with multiple comorbidities.”
Day to day in general practice ● Workload is increasing BUT we can be proactive and bring about change and work in different ways Patient care is becoming more complicated (complex medical needs, ageing ● population) BUT acknowledging we are not alone and there are resources and groups of people who are highly skilled and have the expertise to help the local primary care networks Signposting/education ●
At a practice level ● Recruitment of clinical pharmacist ● Supporting integration and facilitation of the training pathway via Health Education England ● Working across 2 practice sites currently ● Chineham Medical Practice and Whitewater Health
Our hopes for what a clinical Outcomes pharmacist would bring to the Multidisciplinary approach to ● practice working Clinical expertise working within the ● Liaising with patients regarding practice medication Improved communication with ● ● prescribing issues hospital ● practical issues with medication Reconciliation of hospital medication after discharge
Our hopes for what a clinical Outcomes pharmacist would bring to the Looking at best practice to ● practice continue to deliver high ● Audit standards of care ● Complicated issues with ● Care Home medication rationalised and changes made to benefit the patients
What will it mean in practice? ● Enabling a wider range of care options for patients and enabling GPs to focus on patients with more complex needs ● Reinforce links and communication with community pharmacies ● Signposting patients to appropriate services/information
Our aspiration for the future ● Clinics Medication review ● Optimisation of medication ● ● Involvement in improved access session /on the day duty sessions ● Recruit further pharmacist to work with us as we have seen the benefits! Roll out across the PCN ●
Andover MIND Wellbeing workers in practice Emma Hayhoe (Andover MIND) and Dr Tim Cooper (Chineham)
Why focus on Mental Health? ● 90% of adults with mental health problems are supported in primary care. ● 1 in 4 appointments in primary care relate to mental health ● Mental illness is a leading cause of disability in the UK ● Stress, anxiety and depression were the leading cause of lost work days in 2017/18.
What did we do? ● The Wellbeing Worker was based at the surgery in Chineham for 2 hours / week on a Tuesday afternoon ● Directly bookable 30 minute appointments ● The pilot ran for 3 months in total ● Patients aged 16+ ● Basic mental health interventions, signposting and follow up, as well as a comprehensive personalised care plan. ● Clinical information stored in GP records
How did it go? “Listened, longer time to talk, good signposting to other agencies” 70 % would have recommended the service to other people. ● ● 67% of people felt comfortable seeing someone who wasn’t a GP about their mental health After the appointment only 19% were seen by their GP within 2 weeks and ● only 26% within 4 weeks about their MH
What next for Wellbeing workers? ● Plan to roll out across the whole of Whitewater Loddon Network ● Funding jointly from the CCG and Hampshire County Council ● Aim to offer 8 hours per week + of bookable appointments ● Support closer working with our colleagues from Andover MIND
Community Link Nurses Dr Kate McKenna (Whitewater Health)
Why Link Nurses? ● Public Health data shows elderly population in N.Hampshire increasing faster than elsewhere in Hampshire ● There will be an associated increase in the number of frail, elderly, housebound people with complex needs and co-morbidities Consequence of unmet needs and inequality in terms of health ● service provision ● These patients are at higher risk of deterioration and admission
The Role of Link Nurses ● Whitewater Health establish the role of community Link Nurse in 2014 Pilot 100% charity funded in association with the Odiham Cottage Hospital ● trust ● 2 part time (1FTE) community link nurse for population of 17,000 Last few years, Whitewater Health charity has taken over 50% of the funding ● Caseload of 740 patients in the 12 months to Nov 2017 ● Target group Frail elderly with no healthcare contact for a prolonged period ○ ○ Those identified as at risk of deterioration or developing a crisis ○ Those with chronic diseases unable to access GP services ○ Those recognised as having cognitive decline, living alone or not coping in their current home arrangement
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