EASTLEIGH SOUTHERN PARISHES
Practice Based Commissioning Steering Group
Minutes of the Meeting – Wednesday 24th November 2010
Present
Hugh Janes (HJ)
Dr Karl Graham
Dr Simon Goodison
Dr Alan Myer
Dr Peter Das (PD)
Julie Howgate (JH)
Yvonne Owen (YO)
Kim Rowland
Anne silcox
Angela Felton
Catherine McLean (CM)
PBC Manager
Hedge End Medical Centre
Blackthorn Health Centre
St Lukes
West End
Practice Manager Bursledon
Old Anchor Bishopstoke
West End
St Lukes
Blackthorn
Community Pharmacist
1. Apologies for Absence
Dr Vivian Ding
2. Minutes of the last meeting
Agreed as correct
Practice Action Plan Half Year Reviews
1. Blackthorn Health Centre
The practice has actively looked at:
 Ranking Data
 1st Outpatient Referrals
 Non-elective admissions
 Advice & Guidance (choose & book)
 EOL
 Pulmonary Rehab audit
 GOS18 audit quarter 1
 Discharge summary quarter 2
 After death audit
Findings
 Ranking data was fairly static
 There has been a significant rise in ophthalmology, gynae and general
surgery referral
 Differences in referrals to ENT and Orthopaedics were identified between
GP’s
 50% of Ophthalmology referrals were generated from GOS18. Referrals
have now been split between GOS18 and direct referrals and this process
will continue to be reviewed monthly
 There were no alternative pathways identified for Ophthalmology or
Cardiology.
 All GP’s regularly used the MAP of medicine toolkit which has been
installed on every ones desktop
 It was felt that by using Advice and Guidance for Gynaeology and
Neurology would not only reduce referrals but also admissions
 GP acute admissions were considered appropriate with no alternative
pathway
 Antibiotic prescribing over the telephone for incorrect diagnosis may have
led to the condition worsening which in turn may have led to admission
 Introduction of rescue medicines and antibiotics by the respiratory home
care team may have reduced acute admissions
 7 out of the 28 patients reviewed over the age of 65 yrs for non-elective
admissions may have been prevented with enhanced nursing care in the
community, rapid medical assessment step up beds and enhanced
discharge planning
 Increased support over the weekend could have prevented those patients
where were admitted over that weekend but who had been in contact with
the GP on the Friday
 Antibiotic ciprofloxacin used in MRSA patient thought to have precipitated
MRSA sepsis. The practice is planning to invite a microbiologist to come in
to talk to the GP’s re antibiotic prescribing
 Epistaxis admission may have been prevented by the practice
cauterisation or application of topical antibiotic
 Falls – if step-up beds were available for rehab admissions may have
been prevented
 Elderly care/mental health liaison might have prevented admission of
patients with UTI/Dementia
Learning points
 Trial of PPI for chronic cough patients prior to referral to ENT
 Cervical polyps could be removed in the practice
 Rescue antibiotics and steroids for acute exacerbation of COPD could
prevent admission
 Avoid the use of ciprofloxacin in MRSA patients
 Consider support and added needs of patients over the weekend
 GP’s to use Map of Medicine toolkit when uncertain on referral pathway
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Use of emergency HOOF oxygen and increased support over weekends
could reduce the possibility of admission
Alternative Pathways Identified
 GOS18 triage
 Direct referral to gynecology would be useful
 Minor op clinic in the community for hernias and lipomas
 More use of respiratory home care team
 Rapid elderly care medical assessment
 Enhanced nursing in the community and discharge planning
 Step up beds
 Nasal cauterisation for expistaxis could be performed in the practice
 Wax removal for patient with previous perforation in the community
 Adolescent audiology
 Orthopaedic Choice – improved community physio is necessary as poor
provision leads to earlier referral or Orthopaedic Choice
What has been useful
 Meetings to discuss referrals an admissions had be educational
 Discussion about admissions of patients who had been seen in the
previous week
 Non elective admissions of patients aged over 65
 Using the Map of Medicine too
What has been less useful
 Ranking data
 Discussing all patients
 GP’s making own decisions on appropriateness of their referrals which
has not been challenging enough
Future Plans
 GP’s will review each other’s referrals to Dermatology
 GP’s will discuss each referral with another GP if they feel there may be
an alternative pathway
2 St Lukes Surgery
The practice has actively looked at
 Referral data
 Practice Ranking data
 Use of PBC tool
 EOL
 Pulmonary Rehab audit
 GOS18 audit quarter 1
 Discharge summary quarter 2
 After death audit
Findings
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Ranking data was fairly consistent with the activity across the PCT
locality
Numbers have increased for elective admissions
Reduction in A&E attendances
Outpatient 1st referrals are high and the practice are considering how
this can be improved
Highest 3 areas are Orthopaedics, ENT and dermatology
There have been problems within the practice with inappropriate
referrals from locum GP’s
The practice has been going through a very difficult time in the last 9
months with a lot of changes
Not all GP’s are using the Teledermatology pilot
Learning Points
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Over use of locums to meet current shortfalls has been leading to
unnecessary referrals
Teledermatology Pilot needs to be encouraged with all GP’s
Poor Physiotherapy waiting times and direct access to podiatry is a
likely reason why Orthopaedic choice referrals have increased
The practice needs to dedicate a regular weekly meeting to PBC and
look at getting specialist in for educational meetings
The practice needs to organise monthly referral meetings and peer
reviews
Alternative Pathways Identified
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Direct access to podiatry
Quicker Physiotherapy appointments
What has been useful
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Looking at referral data
Identifying inappropriate Locum referrals
3 West End Surgery
The practice has actively looked at
 Referral review
 Teledermatology
 EOL
 Pulmonary Rehab audit
 GOS18 audit quarter 1
 Discharge summary quarter 2

After death audit
Findings
 Referrals recorded weekly and discussed quarterly
 All COPD patients have been referred to the rehabilitation pilot scheme
 Successful use of Teledermatology
Learning Points
 Dr Peter Das acknowledge that there has been a lack of direction within
the practice and they required more help from the locality
 Referrals have been modified appropriately after discussion within the
practice
 Continue to refer to Pulmonary Rehab
 Continue to use Teledermatology
 High A&E attendances were identified and it was agreed to come up
with some form of education/help pack for patients
Alternative Pathways Identified
 GOS18 referral triaged
4 Hedge End Surgery
The practice has actively looked at
 Ranking Activity
 1ST Patient referrals
 Weekly referral data
 Using PBC tool
 EOL
 Pulmonary Rehab audit
 GOS18 audit quarter 1
 Discharge summary quarter 2
 After death audit
 Choose & Book advice and guidance
Findings
 Not all referrals had been initiated by the practice
 A large number of referrals were consultant to consultant
 Follow up appointments were charged as 1ST outpatient appointments
Learning Points
 Using Choose & Book guidance could reduce the number of referrals
 Reduce referrals for was impaction by using a difference pathway
 Invite an ENT consultant for educational meetings
Alternative Pathways Identified
 Nasal Scoping could be done in practice
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ENT wax impaction could be done in the community
Punch biopsy could be carried out in the practice
Acne – initiation specialist prescribing within the locality
What has been useful
 Identifying new pathways
 Looking at referral data
What has been less useful
 The biggest problem the practice has is time for the practice to keep
meeting on a regular basis to discuss referrals and new care pathways
5 Old Anchor Surgery
The practice has actively looked at
 1st Out patient referrals
 Ranking data
 EOL
 Pulmonary Rehab audit
 GOS18 audit quarter 1
 Discharge summary quarter 2
 After death audit
 Medicines management
Findings
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Some referrals were not perceived to benefit the patient
Patients declined surgery when offered
Dermatology referrals could have been dealt with in a community
setting
Patient pressure indicated inappropriate referrals
More education and discussion was needed when explaining a referral
or surgery to the patient
The surgery has recently been without a partner and they have been
using locum GP’s which has resulted in higher referral rates and
possibly inappropriate referrals
Improved care for COPD patients through the pulmonary rehab service
Patients have poor inhaler technique
No access to nebuliser loan and no community rapid response team
Learning Points
 Difficulty in organising meetings due to problems within the practice
 Problems with locums making unnecessary referrals
Alternative Pathways Identified
 Community Rapid response team
 ENT micro suction
What has been useful
What has been less useful
 Biggest problem for the practice is that they have not got a regular
partner and are using locum GP’s
6 Bursledon Surgery
The practice has actively looked at
Findings
Learning Points
Alternative Pathways Identified
What has been useful
What has been less useful
Future Plans
Actions Agreed for the next meeting
A & E Admission’s avoidance audit
Identify 10 patients over 65 yr of age who have over a period of 1 month
(any month)
 Been admitted to either A&E or Eye casualty
 1 day plus
 Who initiated the attendance
 Was there an alternative pathway
Agreed Topics we would work on as a locality
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DVT avoidance – look at referrals
ENT
Gynaecology
Cardiology BNP –
Echo Referrals for Heart Failure
Date of next meeting Steering Group
Wednesday 15th December 2010