GP Provider Support Unit, Birmingham and Solihull

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Thank you to everyone who joined this packed meeting. 


The resources and planning sheets are still accessible here. We aim to confirm the date of the next 2 meetings as soon as possible.

About Improvement Collaboratives

Improvement Collaboratives are a tried and tested approach to primary care development which allow practices to make better improvements with less effort. The approach will already be known to practices who have participated in national programmes such as Time for Care and Productive General Practice Quick Start.

An improvement collaborative is a group of practices who are working on improving a similar aspect of their work – in this case, access. The collaborative meets regularly to share examples of what’s working, solve problems together and develop the next stages of their plan with expert support. The combination of pooled expertise and practice-to-practice sharing of effective solutions helps each team to make more effective changes with less effort than if they did all their work in isolation.

The RAFT programme is facilitating a collaborative for practices in each locality of BSol. We will meet roughly every 6 weeks or so. 

The agenda is set by practices themselves, to ensure we address the top priorities locally as well as national requirements such as those in the QOF QI indicators on access and staff wellbeing

Our priorities in West locality

At our introductory meeting in September, practices discussed in principle the changes they would wish to make in access and workload. The outputs of the meeting are summarised in the document below. 

Bid for ARRS development

We are aware that in West Birmingham, many of our communities are highly mobile and may move in or out of the locality, as well as between GP practices according to available housing, creating challenges in building trust and encouraging / achieving early vaccination. We aim to work with Flourish in partnership with the Vaccines Service to increase uptake of childhood immunisations in areas of low participation. We plan to run an information and signposting campaign which would tie into existing activities with community partners.

The West locality will aim to target all communities with low uptake, with a particular focus on asylum seeker, refugee and migrant (ASMR) communities, where children may be older and unvaccinated and where the impact of unchecked childhood illnesses could be devastating due to close living conditions. This latter objective will be supported Flourish and their plans to undertake in the ASMR bringing together statutory, private and VCFSE providers to map the health needs and available support for these communities.

The West locality will aim to look specifically to support vaccination as part of the maternity pathway, including maternal vaccination and initial infant vaccinations, and have the potential to leverage participation through the “Please, just listen” maternity listening sessions being held around the city and our Core20PLUS5-funded ‘Doula Connectors‘ programme.

The work that we have completed with Flourish through our Primary Care Access workstream, school focus groups and community listening suggests, that the major barriers to childhood immunisations uptake will be

  • lack of trust in vaccines and the NHS itself
  • misconceptions about side effects and resulting harms spread via social media, especially hyper-local WhatsApp groups
  • generalised difficulty in booking primary care appointments

Outcome Measures

  • increasing the number of additional children vaccinated
  1. a) overall
  2. b) in particular target groups and
  3. c) within the optimal time bracket; decreasing the number of DNAs for vaccine appointments;
  • decreasing staff time spent on chasing these appointments
  • increasing the level of trust in the NHS and understanding of vaccines
  • Improving access to appointments through promoting use of the NHS app

Required Staff

  • X3 Social Prescribing Link Workers

We propose using nursing associates at the hub to deliver a simple dressing and wound care programme to support all West Birmingham patients and PCNs following the withdrawal of the BCHC service previously delivered at Summerfield for over a decade. The current West Birmingham practices cannot currently take this work up effectively due to lack of training and experience, therefore this provides a perfect opportunity to create an evidence based wound dressing process.

There is evidence that wound dressings and leg ulcers cost health care systems millions in dressing costs, appointments, and complications, not to mention lost workdays and morbidity, low mood that impacts society wider leading to increased appointments in primary, secondary and community care.  There is evidence that self-care of some simple dressings reduces cost of dressings, number of appointments and complications. By setting the wound care service in the hub the work will be delivered by fewer, but more experienced staff utilising the formulary cost effective dressings.  The hub option allows us to more effectively use self-care to empower patients, reduce complications and help with dressing costs to the wider system. 

We propose delivering this with nursing associates to deliver the dressing changes and education either in individual or group settings, with the backup of an ACP prescriber to prescribe dressings and antibiotics if indicated without the need for further appointments in practice improving access at sites. 

We plan to liaise with BCHC nursing teams to see what dressing protocols they already have and develop further integration links into more specialist dressing clinics and support.  Ideally, we would buy time from their prescribing team as the ACP to improve integration. We hope that this project will help to develop a better long term wound dressing process which can be appropriately commissioned in the future. 

Patients would also have access to social prescriber if they are also frail.

Outcome Measures

  • Number of appointments delivered at the hub.
  • Number patients given wound/self-care education.
  • Number patients delivering self-care.
  • Use of formulary dressings.
  • Use of patient engagement score to assess pre and post education.

 Required Staff

  • X1 ACP
  • X2 Nursing Associates
  • X1 Care Coordinators

We propose working with Nishkam and Flourish to fund 3 social prescribers to proactively contact housebound patients and frail patients from all West Birmingham PCNs to review winter needs and offer support to reduce exacerbations of their existing conditions over winter.

Examples of interventions include: – advice re winter fuel support, how to stay warm, befriending, identify if needs flu jab/ bloods /QOF review etc then either provide support materials, signpost to appropriate support within the groups, or put on home visit review. By offering support and interventions that reduce exacerbations we hope to reduce admissions over winter in this group.

Outcome Measures

  • Number of patients contacted from each PCN – searches to be designed to target highest risk
  • Number receiving supportive conversation.
  • Number signposted to support.
  • Support pack and accurx messages which can be used again.
  • Number signposted to Home visit

Required Staff

  • X3 Social Prescribing Link Workers

We propose to proactively target and review all housebound registered patients, who are not on the DN caseload within the Locality. Housebound patients are typically elderly with multiple comorbidities and on complex drug regimes. Patients require significant support to manage their health and avoid prolonged hospital admissions.

We are aware of the strain on the community nursing teams. Currently District Nursing teams will only assess and review, including providing necessary blood tests, to those patients already on their caseload. This results in a number of housebound patients not receiving timely review of their chronic illnesses including drug monitoring with resulting pressure on GP’s to go out on a home visit in order to achieve this. It also increases DN workload as patients are referred for other reasons in order to get a patient on the caseload and hence a blood test.

By providing phlebotomy and basic QOF checks such as bp, weight, diabetic foot checks and flu vaccinations it will allow improved outcome measures, higher QOF achievement and reduced hospital admissions freeing up more appointments for both GP and community nursing teams over the winter.

We will work closely with each GP practice on a rotational basis to go through their list of housebound patients and arrange a prebooked home visit by our team to review the patient.

In addition to staff costs, we would require costing for x2 bp machine, x2 weighing scales, bloodletting equipment, additional funding will be required to provide appropriate vehicle insurance and fuel.

Outcome Measures

  • Number of housebound patients contacted – searches designed to review those NOT on DN lists
  • Number of blood tests provided
  • Number of BP / weight checks done
  • Number of flu vaccinations provided

Required Staff

  • X1 Care Coordinator
  • X1 Paramedic
  • X1 Physicians Associate

The West Birmingham Enhanced Respiratory Pathway proposal aims to build on the integrated locality hub work to support winter resilience. We propose funding for a service model that provides proactive care for a risk stratified population of severe/poorly controlled respiratory patients and enhanced acute pathways for those patients identified ad hoc through other service entry points such as 111 or UTC.  

We have chosen this area to support the seasonal winter surge in respiratory cases and due to the high incidence of respiratory illness and respiratory related morbidity and mortality in West Birmingham. We hope this will demonstrate potential system impact by providing a level of care and access that is not possible at individual practice level.

Our planned pathway supports neighbourhood integration models, and we hope that the learning will be transferrable to other pathways as well.

The planned pathway would provide a bypass number for patients identified to be at substantial risk of exacerbation of respiratory disease by risk stratifying all general practice patients in West Birmingham. These patients would have priority access to an ACP to contact in the case of early respiratory deterioration. The ACP would then be able to review the patient, offer rescue medication/treatment and follow up. Management would address holistic care needs through social prescribing support and chronic disease management planning/review. This pathway would also integrate with the virtual ward/frailty MDT and receive patients from ad hoc identification of respiratory exacerbation.

If acute cases do not provide sufficient workload, the ACP could proactively review patients on the high-risk registers to ensure optimised management over the winter period.

Outcomes Measures

  • Definition of risk stratification process, and SOP for pathway
  • Number of appointments offered to priority access patients
  • Number of patients seen
  • Outcome of patients that access hub for deterioration including final disposition (e.g. recovered at home vs A&E)
  • Patient satisfaction
  • Number of proactive reviews.
  • Number of patients referred to social prescriber or virtual ward

Required Staff

  • X1 Social Prescribing Link Worker
  • X1 ACP
  • X1 Care Coordinator

The purpose of this work stream is to address the HI faced by men in West Birmingham. The average life expectancy for men in West Birmingham is 10 years less than other areas within BSol. We want address some of the issues faced including access, awareness and screening.

Working with the relevant ICS teams as well as community organisations and key system partners we will be hosting a series of events to improve access to General Practice through promoting use of NHS app as well as offering hypertension, diabetes, mental health, blood and organ donation as well as cancer screening.

We are working closely with the BLACHIR taskforce, FLOURISH, SWBH and Aston Villa Foundation alongside Prostate Cancer UK to host community wide events offering the above proposed interventions as well as prostate cancer awareness and screening to those at-risk groups. We shall work with community partners to actively promote these events in community forums, social media, radio. We plan to offer appropriate education, awareness and screening opportunities and ensure follow up with the patients GP and secondary care referral where necessary.

Outcome measures

  • Number of attendees to each event
  • Number of BP checks done
  • Number of blood sugar checks
  • Number of people activated on the NHS app
  • Number of people offered PSA screening with onward referral where necessary

Required Staff

  • X1 Social Prescribing Link Worker
  • X1 ACP
  • X1 GP Assistant
  • X1 Care Coordinator

Total Staff required for Locality level working 23/24

  • X8 Social Prescribing Link Worker
  • X3 ACP
  • X2 Nursing Associates
  • X4 Care Coordinator
  • X1 Paramedic
  • X1 Physicians Associate
  • X1 GP Assistant

Your thoughts

Audit on avoidable appointments

Most practices find that a significant proportion of GP / ANP appointments could have been avoided. Measuring this – and the specific changes that could be made – is very helpful in identifying your priorities.

The PSU is developing a free audit tool to support the collection and analysis of this data, to inform your discussions and plans. This will contribute towards your QOF achievements in 2023/24. 

Read more

Demo of the audit tool

Demo of the results dashboard

What do you think?

Action planning

Below are 3 planning templates, for different levels of detail. Select the one that suits your current situation best.