Innovation in Practices
Since September 2012, the Practice Innovation Network has been engaging and supporting its first wave of committed member practices led by the desire to innovate locally. Innovation in Practices is NAPC's first innovation project and describes the unique challenges and successes of tem practices as they pursue continuous improvement.
Our successful project participants act as networked learning organisations with the explicit commitment to pursue continuous improvement. These practices share their challenges and their successes, building knowledge and capability as they learn together.
September 2012 - March 2014
Watling Medical Centre, Burnt Oak & Stanmore
Lead: Paula McLaren, Practice Nurse, Dr Sanjiv Ahluwalia Project: The Health and Social Care Navigator
This project was developed in response to the recognition that as primary care practitioners, although we manage those with complex conditions we continue to react to acute crises in patients’ lives. This project is aimed at providing proactive, integrated approaches to health and wellbeing for patients and their families.
Specifically, we want to provide more timely access to social and health related resources in order to maximise health and well-being of patients, families and carers as well as reducing inequality by providing timely and appropriate access to support and service. General practice ideally placed to provide a hub for individuals to access health and well-being resources
We believe in order to achieve best practice, as a practice we need to develop proactive service, aligned to the patient-centred approach, which targets individuals early who may benefit from specific intervention to support their physical, psychological and social needs, thereby enhancing the wellness agenda.
The project will target individuals who may benefit, offer advice, support, referral and follow up. The health care navigator will develop links and build relationships with local, third part organisations and provide ongoing development and training of staff. It is hoped that once the role is established, the role may be rolled out to other practices in the network.
Cricket Green Medical Practice, Mitcham
Lead: Dr Simon Gilbert Project: Wellbeing Project
The project aims to create a self-sustaining Wellbeing community based around a GP practice of 9000 patients and the surrounding population. Their initial funding has been used to free up time to coordinate the project and identify and engage members of the local community to develop Wellbeing projects. These include a Practice open day with over 90 patients and 40 representative of charities, community groups and agencies; a walking tour with a view to starting a walking group at the practice; and development of a website to showcase local Wellbeing projects and signpost to local services. ‘We have been excited by the level of community engagement so far and hope to have a critical self-sustaining mass of support and involvement by the end of the year.’ Dr Simon Gilbert.
Wallingbrook Health Group, Devon
Lead: Karen Acott Projects: Community Health Opportunities/Know your numbers/Pharmacist Multimorbidity Review
Community Health Opportunities
Wallingbrook were inspired by the 5 ways to wellbeing message of Connecting, Learning, being Active, Noticing and Giving (CLANG). They aim to encourage communities in their rural area to use their collective knowledge to raise awareness of existing facilities, activities and groups with the aim of improving participation in healthy activities. They are encouraging their PPG to lead on this project and develop a healthy living week campaign.
Know Your Numbers
The Practice and Patient Participation Group (PPG) wished to empower patients and to make it easy for them to monitor key health measures without needing to make an appointment by creating a MOT Bay. Wallingbrook are promoting the Know Your Numbers campaign to ensure patients feel empowered to come and use the facilities. The aim is to help patients in understanding key measures i.e. waist circumference, BMI, blood pressure and FEV1 mean and how regular monitoring can inform their health status and the beneficial impact of lifestyle adjustments.
Pharmacist Multimorbidity Review
Wallingbrook asked the question, why do some patients with long-term conditions feel well and
others don’t? They saw multimorbidity as an increasing problem and wanted to look at novel ways of approaching it. They aim to utilise the skills of a clinical pharmacist to improve patients’ understanding of their condition, medications and explore their attitude towards their chronic disease and barriers to their wellbeing.
St Hilary Group Practice, Wallasey
Lead: Dr James Kingsland and Dr Vishal Nosib Project: Urgent Care Project
This project is to assess and address an increasing demand on urgent care systems, which are becoming overstretched despite increasing resources. St Hilary Group Practice aim to review urgent care activity and assess demand for patient access to urgent care. They will assess necessity and appropriateness of contacts and consultations and the potential for extending GP 'in hours' service. In order to assess progress, they will use patient experience and demand on urgent care provision, to see how this changes as the service provided changes.
Oxford Terrace Medical Group
Lead: Sheinaz Stansfield Project: Improving Self-Management with an Integrated Approach to Diabetic Care
This project is aimed at engaging people aged 40 years and under with type 1 diabetes. Those in transition between children and adult services will be particularly targeted. Although few in number, they make disproportionate use of urgent care services, whilst not making adequate use of core primary care services. This results in poor health and well-being and poor health outcomes. The aim is to provide patient centred proactive case management and using a patient centred approach, ie care to the patient rather than patient to the practice. The potential outcomes include: improved self care and physical health and better compliance in medication, leading to reduction in use of unscheduled care, improved mental health and sense of wellbeing and a reduced risk of long term complications.
Halton Clinical Commissioning Group
Project: Community Wellbeing Peer Mentors, Leads: Mark Swift, Lindsay Marsden
Wellbeing Enterprises is an award winning social enterprise - our mission is to support individuals and communities to achieve better health and wellbeing. We do this by educating the general public; unlocking the assets within our communities and working collaboratively with our partners to tackle the underlying causes of poor health. As a social enterprise, we play a vital role in the provision of innovative and highly effective community programmes that support individuals and communities to develop their resilience levels and to improve their sense of wellbeing. We are leading the way with the development and delivery of psychosocial interventions for people who are living with physical and mental health problems, one of our key strengths being in the area of social prescribing.
Wellbeing Enterprises is the first organisation in the country to secure a contract with a Clinical Commissioning Group to develop social value responses to improve health and wellbeing. Community Wellbeing Practices (CWP) was launched in October 2012 and it centres on aligning community assets around GP practices, supported by a Wellbeing team who respond to the psychosocial needs of patients. We work with partners to develop a way of addressing the social problems that often underlie patients’ presentations at GP surgeries - which can often lie at the root of their health problems, or be an exacerbatory factor.
We are creating an established base of ‘Community Wellbeing Peer Mentors’ who are supported to utilise their own skills and experiences to improve the health and wellbeing of themselves and the community in which they live through engagement in the primary care setting. Our volunteer offer includes a bespoke training and development plan for each volunteer and offers a range of exciting and creative volunteer job opportunities.
Practice: South Lewisham Group Practice
Lead: Dr Arun Gupta Project: Diabetes-Improving Self Management
A partnership between the patient and healthcare professionals. Giving information to patients about many aspects of their condition is curtailed by time available. There are many sources for information and often patients get lost in the maze. Using Sounddoctor, South Lewisham aim to give patients access to positive messages to help them understand and live with their condition. It can be accessed repeatedly to reinforce understanding and motivation, both for those who are motivated and those that need extra encouragement. Many patients have access to the internet or a smartphone and are able to look at or hear information on-line. This project aims to see if Sounddoctor can help patients self manage their condition better.
Fieldhouse Medical Group, Grimsby
Leads: Dr Jon Plotnek & John Noton Project: Health Pod and Managing anxiety and Depression in Patients with Chronic diseases
In a climate of rising Chronic Disease, an ageing Population and an increasing workload with limited resources, Fieldhouse resolved to provide a high quality accessible service using greater engagement from patients in both managing their health conditions and the lifestyle choices that impact on them. Fieldhouse are providing equipment for patients to self-manage blood pressure and complete life style questionnaires. They aim to develop a service to provide psychological therapy input to help these patients manage the anxiety and depression that their physical illness brings.
The practice is also looking to further develop its close working relationship of its community nursing teams, which has historically been innovative, but influence has been further improved as Fieldhouse is one of the shareholders in the not for profit company that operates the community nursing services.
Ballater Surgery, Bromley
Leads: Dr Jackie Tavabie, Dr Bart Tyszka Project: The Patient Liaison Officer in General Practice
In common with many practices, Ballater has an increasingly elderly population with multiple co-morbidities , and a workforce experiencing increasing workload and demand for clincial time. In response, they have developed the role of a Patient Liaison Offoice (PLO) to support clinicians in managing complex care for housebound patients and their carers. This is a new role in general practice and aims to imporve the patienct expereince and outcome of care, through ensuring that care is coordinated between general practice and other community care and secondary care providers. It involves active liaison between the PLO; patients and carers, and the providers of care, enabling the general practice to maintain up to date records of care and patient need. Through support of patients and carers they aim to reduce avoidable hospital admission and avoid crises through impored communication and planned care
Moatfield Surgery, East Grinstead
Lead: Dr Minesh Patel, Heike Burnett Project: Frail Elderly Care Coordination
Primary and community care faces a rising challenge to provide proactive and coordinated care for people with increasingly complex care needs. Practices currently provide reactive care, a suboptimal care delivery for patient and practice in addition to barriers for primary and community services to share and widen their skills mix.
The Practice undertakes to improve its healthcare provision with emphasis on the frail elderly in conjunction with the development of multidisciplinary health and social care teams and their training needs. Patients at high risk of need are identified through risk stratification and the clinical team. It is hoped that a continuum of care for the frail elderly with a broad range of services matched to individual need, will reduce crisis management, urgent care access, inequalities and ensure better patient experience.