|Lead GP – Dr John Keene
|Lead PM – Alison Stewart
|Lead PN – Sarah Ashworth
The Pudsey locality comprises 5 Practices with a patient population of 42K who are working together to improve the health and well-being of the Pudsey residents.
Our shared ethos is:
- To create a stronger team
- To preserve the core values at a local level whilst benefitting from economies of scale
- To flourish
- To be the best for our patients, working smarter and more sustainably
To ensure patients have 7 day access to care we provide a Hub located at the Gables Surgery. Patients from all 5 practices can access the hub and book both appointments in advance and on the day urgent appointments.
The year 2016-17 was our first full year of working together to improve the health of the patients in the Pudsey area. We analysed our data and identified 3 areas we needed to focus on.
- Holistic care of patients with COPD
There is a high prevalence of COPD in the locality as a result of deprivation, a high historical prevalence of smoking (especially amongst males) and high exposure to industrial environmental pollutants.
Admission rates to Leeds hospitals for COPD are higher than the national average, suggesting suboptimal management of COPD.
We reviewed the COPD registers – the aim was not to specifically increase them – but to ensure we had captured all the patients to ensure correct treatment.
We put in place reviews of COPD patients within 2 weeks of discharge from hospital – as per NICE guidelines and increased referrals to Pulmonary rehab.
People with advanced COPD were identified and offered appropriate Palliative care to address their needs.
- Obesity identification and support in promoting weight loss
The locality has a higher than average prevalence of obesity. Obesity is an important cause and contributor to comorbidities and mortality. None of the 5 practices had weight management clinics.
We aimed to review weight management services and implement improvements to reduce morbidity from obesity in the local practice population. We focussed on the following comorbidities: diabetes, CVD disease and cancer, which are above average in our population.
Using NICE guidelines we agreed a common method of classification of obesity
Class 1 – BMI 30 – 34.9
Class 2 – BMI 35 – 39.9
Class 3 – BMI 40 or more
The obesity template created included recording waist and hip circumference which provides information about the distribution of body fat and is a measure of risk for conditions such as coronary heart disease (CHD).
Once these patients were identified we worked with LCH to provide a weight management service for the Locality – vastly increasing the number of referrals to the service.
Those patients who had been identified as not having a BMI recorded in the past 18 months were recalled to attend weight clinics – again this gave an opportunity to offer referrals and general health education.
- Support of carers in the community
The number of carers in the Pudsey locality is ranked 4th in Leeds, 1347 people out of a population 35,000 provide more than 50 hours of care each.
We know from experience that this group don’t get the support they need patient care suffers and hospital admission are more likely.
Classification of who was a carer differed across practices – working with Carers Leeds we established a common classification & obtained data on the yellow card referrals to Carers Leeds.
Once identified we were able to offer annual health checks – focusing on both the physical and psychological health of the carer.
If necessary, referrals to other agencies for support could be made.
Proactively targeted patients on the 2% list and some QOF registers.
As with our at risk patients, carers were offered flu vaccinations to help avoid contracting flu and thus not be able to keep up their caring role.
We have hosted a carers day at one of the practices.
We have planned a target educational session for clinical and admin staff.
Pudsey now part of the Citywide Carers Partnership.
Moving into our second year our collaboration continues to grow. We now hold the following forums:
- Bi Monthly Locality Nurse Forum
- Bi Monthly Community Wellbeing Meeting – bringing together statutory, voluntary and 3rd sector organistions working across the population in Pudsey
- Twice yearly Pudsey Wide Target Events for Clinical Staff – we are introducing an admin target this year
- A Pudsey wide PPG – meeting every 6 months
- Quarterly Locality Meetings with a clinical and a management lead from each practice
- Quarterly Hub Clinical review meetings
We are working with LCH to develop an elective care pathway for community diabetic services co-locating in Hillfoot.
We have identified the following Priorities as our focus for 2017-18.
- Increase in referrals to the national diabetes prevention programme and for patients with diabetes referral to structured education
- Increase in the recorded prevalence of hypertension
- Carers: Continue to build upon the work undertaken in 2016-17
- Increased number of carers offered healthchecks & flu vaccination
- Increase the number of carers on the Register
- Work with Carers Leeds to develop a training package for admin staff
- All practices to have completed training by March 2018
- Develop a good practice guide for supporting carers
We are also trialling new ways of working through the following 2 pilots:
Employing a Prescribing Pharmacist to work across the 5 Practices to undertake patient facing clinics.
Employing an advanced skills physiotherapist to work across the 5 practices to undertake clinics for patients with Muskuloskeletal problems.