Southwark PCT: Hypertension Working Group Draft Action Plan 3/2007 – 02/2008 Issues being addressed Actions to be undertaken Progress criteria and Resource implications who? when tangible outcomes By By ? General Practices Variation in prevalence 1. Practice visits involving problem AB 02/08 1.a Incremental QoF Need for input in protected indicating possible solving using ideas contained in MI and improvement and closing of learning time. under-diagnosis of tool kit by practices to address SC gaps on BP1, 4 and 5. hypertension clinical and organisational factors 1b. Greater consistency of More MI toolkits. which may impair performance. achievement across practices Variability in quality of Will initially address reasons for in the PCT Possible need for more IT service delivery of variation in prevalence. (1st quarter support if boost to practice’s effective 2007) All 2a/3 Improvements in usage of systems required for pharmacological and 2. Programme of further work and detection and management to better performance. non-pharmacological targeted practice support to be be monitored quarterly. management of hbp. determined in light of QoF 2007 AT 2b Meet LDP targets of 12% results for BP1, 4 and 5. LH detected prevalence and 70% 3. Practices to receive early and <150/90. Aim for PSA stretch feedback regarding achievement on KP targets of 15% detected blood pressure targets and prevalence and 75% <150/90. contextual information (e.g. socio- demographic). 4. Encourage practices to appoint 7/07 4. Database of hypertension hypertension leads. leads for the 48 practices. Enhancement of evidence-based best practice across all primary care (GP teams, practice and district nurses, health care assistants and health trainers) Need to ensure best 1. Local guidelines being produced AB 5/07 1. Local guidelines Input from PCT practice guidelines for all primary care community AP professionally produced and Communications dept to followed by all health staff – collation of national JJ distributed widely. Placed on ensure best format and care professionals. guidelines (NICE, JBS2, BHS) for intranet. (Consider placing presentation of information. hands on use plus locally applicable elements of it on public Need to consider training information re practicalities: drug website also to foster a Conference space, Southwark PCT: Hypertension Working Group Draft Action Plan 3/2007 – 02/2008 Issues being addressed Actions to be undertaken Progress criteria and Resource implications who? when tangible outcomes By By ? available and possible algorithm, systems, equipment, care Tba partnership approach between refreshments, display gaps to ensure best pathways. hcps and patients.) materials and publicity practice followed... 2a Presentation to Professional and LH Launch event and training. Executive committee (Mar 2007) to + 03/07 2. Move hypertension up the Need to improve shared update and explore how best to all agenda. Greater proactivity management and ground the work. around hypertension by all continuity if care. e.g. 2b Presentation of current work of 05/07 hcps. management of hypertension to be made at 3. More training available on hypertension in the Protected Learning Session on regular basis in the PCT to housebound. LTCs ensure best practice, 3. Additional training being sought LH increased confidence, Need to move for Health Care Assistants and AB improvements in shared hypertension up the Health Trainers to build capacity AT management and continuity clinical agenda. and understanding in the PCT. All of care. Clinical Governance Resource Group (Lambeth and Southwark PCTs) Need to optimise 1. Large scale clinical audit of gps, CT tba Recommendations of audit. Possible need for locally pharmacological pharmacies and patients (March + 1. Ensure Community enhanced service. treatment of 2007) all Pharmacists are linked to the hypertension and wider Hypertension work. increase patient (Possibility of Increased Training for pharmacists understanding of availability of blood pressure undertaking bp checks. medication related checks in pharmacies) Development of local issues. Community 2. Examine training needs protocols. pharmacists are well 9/07 3.a Encourage CP placed to make contact participation in the Know with patients and support your Numbers campaign in concordance. September. 3b collection of data and Southwark PCT: Hypertension Working Group Draft Action Plan 3/2007 – 02/2008 Issues being addressed Actions to be undertaken Progress criteria and Resource implications who? when tangible outcomes By By ? evaluation to look at usefulness of exercise Know Your Numbers Week (Sept 10th-16th 2007) Low awareness and a 1. Implement the Blood Pressure All 09/07 1.,3. Visible campaign and Communications support number of Association’s national campaign high quality publicity across misconceptions amongst Know Your Numbers in the PCT. Southwark. Lambeth and Southwark 2. Devise strategy to encourage LH 05/07 2. Strategy drawn up and residents regarding participation from a range of and stakeholders consulted hypertension. (MORI stakeholders AT enquiry (2005) 3. Continue working in conjunction All with Modernisation Initiative to MI raise awareness of hypertension. Community Pharmacies and Medicines Management Need for more 1. Present at Community pharmacy AD 6 / 07 1. Closer working collaboration with forum – LPC approached re: dates K/ relationship with community community pharmacists H pharmacists in area of 2. NICE algorithm to all practices W 04/07 hypertension Guidelines with preferred agents highlighted. / 2. Guidelines distributed implementation (include with local guidelines) LH widely following sign off 3. Pilot BP screening in community Pilot 3. New patients identified in Undiagnosed pharmacies and investigate long-term H to community pharmacies and hypertension funding for wider roll-out. ? W start referred to GPs. through enhanced services and 5/ 07 4. Promote concordance package A- 4. Inaugural training in from MI D Southwark PCT Poor medicines 5. Investigate what literature is K 9/07 5. Advice available regarding optimisation available at Health First and if it TA useful information. Lack of patient finds its way to practices. What info H Information to be readily Southwark PCT: Hypertension Working Group Draft Action Plan 3/2007 – 02/2008 Issues being addressed Actions to be undertaken Progress criteria and Resource implications who? when tangible outcomes By By ? understanding. do practices use? W available to all healthcare staff. Elderly people and others supported to live at home with care plans Links to social care Members of group to meet1. with AT 8/07 1. Outline needs assessment Need for better relevant staff from social care to + completed and action plan understanding as to examine issue and identify needs. all developed for dealing with any how anti-hypertensive problems identified. medication is dealt with within care plans. CVD Risk Register Need to address global 1. Support practices in setting up and G 1a.Number of practices signed Locally enhanced service. CV risk making use of CVD risk registers o’ up. DA 1b. Validation of registers B, 1c. Improvements in AT management of hypertension and and longer prevention of LH stroke, CHD and renal disease Interface with secondary care Problems of 1. Research to be undertaken into SS 1. Clarification as to factors Research being undertaken at measurement of a distinguishing resistant hypertension implicated in resistant KCH blood pressure. Need from patient’s non-compliance with hypertension. for improved medication. Evidence base for targeted concordance. action to improve concordance More skill sharing locally. between secondary and primary care. More research into management of Southwark PCT: Hypertension Working Group Draft Action Plan 3/2007 – 02/2008 Issues being addressed Actions to be undertaken Progress criteria and Resource implications who? when tangible outcomes By By ? hypertension in primary care. People involved in implementation: Afaf Boutros – AB (Quality Improvement lead for long term conditions) Ann-Dora Kwame – ADK (Medicines Management) Alison Pisani – (Nurse Practitioner Aylesbury Partnership), Alex Trouton – AT (Health Policy Officer Southwark Public health), Christy Tilney – CT (Southwark PCT), Geraldine o’dea – G o’D (Public Health Consultant and lead for Long Term Conditions) , Helen Williams- HW (Modernisation Initiative specialist pharmacist) Jenny Jones – JJ (District Nurse manager, Bermondsey Health Centre Joanna Guilar – JG (Health Priorities Manager Southwark PCT), Karen Philips – KP (Public Health Information Officer), Latha Hapugoda – LH (Public Health specialist and Hypertension working Group chair) , Penny Ackland – PA, (GP in Dulwich) Tony Afuwape – TA (Hypertension Improvement lead at Modernisation Initiative) Shirley Coleman – SC (Data Quality Facilitator Southwark PCT), Selva Saman - SS (Association Specialist Kings College Hospital), Yvonneke Roe - YR (GP in Dulwich and Chair of Peckham and Camberwell Hypertension Action Group).
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