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									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

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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

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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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