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RCGP Bright Ideas, 'Pioneer' Award winners 2019
RCGP Cluster Innovation Award winners, South Powys Cluster 2019

Clinical Outcomes coordinator

Acute Physiotherapy

Medicines Management Team

Nurse Triage

Total Nurse Triage

In 2016, Red Kite commissioned the services of the mental health charity MIND to provide in-house services across the locality for low level mental health issues. The program consists of trained practitioners working within the surgeries who patients can be directly referred in to, often the same week. A five week self-help program under the guidance of the active monitoring practitioners is undertaken and has been hugely successful in aiding patients with a range of issues, such as grief and anxiety that can be addressed early and effectively without the requirement for onward referrals. Patient feedback for this service was extremely positive with outcomes showing a reduction in the number of patients returning to their GP after completing the program. In 2018, Red Kite handed this service to Powys Teaching Health Board who now use this alongside silvercloud as an online CBT program.

Mind-Active Monitoring

Remote Triage

CRP Point Of Care Testing

The donation of 8 CRP testing machines to the practices was undertaken by Red Kite in October 2018, to aid clinical staff with the antibiotic treatment of lower respiratory tract infections. A finger- prick blood sample can be taken from the patient with a result obtained within 2 minutes, showing the levels of infection within the patient. Results can then be used to assist clinicians with the prescribing of antibiotics. Results across the cluster have shown a 17% reduction in antibiotic prescribing for these patients. With the media and healthcare focus on antibiotic resistance, the use of these machines has been greatly welcomed in primary care.

Medicines Management Team

In 2015 Red Kite introduced the role of the Pharmacy team in to the South Powys Practices. The team now consists of 5 Pharmacists and 5 Pharmacy technicians working from within the practices. The team has drastically reduced the workload on the clinicians by dealing with all medicines reconciliations, hospital discharges and appropriate clinical letters. In addition to this, they deal with patient/carer/consultant queries, provide chronic disease clinics, and instant access for a range of clinical areas such as DMARD monitoring and warfarin control. 


Nurse Triage

A large proportion of a working day in practice can see clinicians dealing with requests for urgent, on the day appointments for acute illnesses. With 80% of GP partners in South Powys being 50+ and practices across Wales struggling to recruit it is imperative that GP's only see patients who need to be seen by a Doctor. Analysis has shown that a large proportion of the ailments being seen could be effectively treated through triage and effective use of all health services; including referral in to the Pharmacy team, Community Pharmacy, Optician, Active Monitoring and a range of other services. Signposting reduces waiting times and improves access and treatments for patients who are acutely unwell. Patients who telephone the surgery requesting an urgent appointment are telephoned back by a Triage Nurse who will assess their symptoms and advise on the best course of action. This ensures the patient receives advice and treatment in a timely and effective manner by the most appropriate service. Statistics show that, on average, 69% of patients requesting on the day appointments do not require a GP appointment with a further 19% requiring advice only.


Total Nurse Triage  

Following the introduction of the successful Nurse Triage service for on the day appointment requests across South Powys practices, Haygarth Doctors extended this service to incorporate Total Nurse Triage for all appointment requests (urgent and routine) from February 2017. The success of this pilot was unprecedented, ensuring that each patient always sees the most appropriate clinician within a suitable timescale. Within two months routine waiting times fell from 1-2 weeks to within 48-72 hours for most appointments. All routine appointment times were increased from ten to fifteen minutes, allowing GP's to spend more time with patients. Patient feedback has been largely positive with waiting times reduced and patients often pleased to have avoided an unnecessary visit to their GP for a problem that has been dealt with through triage. Current figures show an average of 42% of patients requesting a routine appointment have been signposted to other appropriate services. 16% of patients require advice only notably, 8% who have requested a routine appointment, but when triaged the Nurse felt the patient needed to be seen more urgently, having their appointment expedited, thus ensuring they have received the best quality of care.


Remote Triage

Following the implementation of the successful scheduled Triage service in the Haygarth practice, the next phase was to look at ways to expand the service within the cluster and the current compliment of Triage Nurses. The aim of providing remote access across sites is to demonstrate that assistance can be available between practices to provide sustainability support to practices, or to enable gap fill within the current triage systems. As part of our extended services, the Haygarth practice have were able to offer and extend the triage service to include a trial of remote triage. Triage Nurses based in the practice, were able to provide triage for other practices from base to ensure the system continues during periods of sickness or where there are recruitment/ workforce issues. Use of this service was successfully trialled and relieved pressure on clinical staff, allowing us to streamline services and ensure that patient services are not interrupted. Current figures show an average of 59% of patients requesting an emergency appointment have been signposted to other appropriate services. 23% of patients require advice only, 14% who have requested an emergency appointment only required a routine appointment.


Primary Care Pain Management

COVID-19 Impact Service

Primary Care Pain Management

The aim of this service will be focused on providing an early intervention and medication reduction service through a Pain Management Practitioner in the practices. Patients that are identified and/or highlighted in the Primary care setting as being at risk of developing an addiction or reliance can be introduced to early intervention measures, including advice, face-to-face consultation and support. In addition to this, the Practitioner would also target patients with long-term misuse that will require a comprehensive treatment programme to enable them to regain control of their lives and reduce their reliance on pain medication. Working closely with Primary and Secondary Care colleagues, this service aims to reduce routine GP appointments, increase knowledge of pain management, improve patient compliance and encourage patient self-care. This would see an overall reduction in the misuse of opioid and gabapentinoid medication in South Powys.

COVID-19 Impact Service

COVID-19 Impact Service provides a telephone support service over a 12-month period for patients effected by the impact of COVID-19 at a local level. It will identify shielding/vulnerable patients through the practices clinical systems who may not have accessed services during the pandemic; or who may be reluctant to re-enter society. Patients are contacted via the telephone and given advice relating to service provision that is available; the opportunity to discuss the safety measures in the practices; access to the booking of health appointments; including signposting to cancer screening, voluntary and community services and health promotion. Sign-posting patients to community services where applicable in their local area, particularly in response to mental health needs and the impact of the lockdown and isolation.



Acute Physiotherapy

Musculoskeletal problems make up around 30% of GP`s workload. Most of these cases can be managed most effectively by a Physiotherapist. With increasing constraints on GP appointments, increased requests for pain control medication and often-lengthy waits for patients referred to a traditional Physiotherapy service, the South Powys cluster decided to roll out a pilot service consisted of a Physiotherapist running in-house clinics to look to improve outcomes for all patients across South Powys.

Red Kite secured the services from Powys Teaching Health Board of two highly qualified Physiotherapists to work in the practices for acute pain issues. This allows patients almost immediate access to the correct health professional to deal with their problems, often starting treatment straight away and preventing unnecessary referrals and investigations.


Clinical Outcomes coordinator

Collecting outcome data is vital to our projects, knowing what you do works is vital in providing effective healthcare. The role supports the collection and reporting of patient clinical outcomes for all the services run by Red Kite. It allows us to constantly evaluate and improve our services as well as ensuring we deliver patient centred outcomes. Our appointment of a clinical outcomes coordinator was an important step in this process. We are able to look at interventions and outcome improvements across all of the practices, see what works and highlight areas where we can focus and improve services.


Acute Physiotherapy Report Pharmaceutical Team Activity Unscheduled Triage Report Scheduled Triage Report Remote Triage Report Pain Management Service Report COVID-19 Impact Service POC TESTING EVALUATION SOUTH POWYS Mind Report

Atrial Fibrillation (AF)

Atrial Fibrillation (AF)

Atrial Fibrillation (AF) is an irregular and often rapid heart rate that can increase the risk of stroke, heart failure and other heart-related complications. AF may come and go (paroxysmal AF) or may be permanent (BHF, 2020). One of the major concerns of AF is the potential to develop blood clots within the upper chambers of the heart that can travel to other areas, blocking blood supply (ischemia).

Through the aims of the stop-a-stroke campaign the CIC looked to support the cluster with the opportunistic capture of abnormal pulses for patients attending the surgery. As the chances of AF increase with age, the Influenza vaccination Programme was deemed to be an ideal opportunity to capture a large cohort of patients.



AF - Stop a Stroke

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Clinical Outcomes coordinator







Acute Physiotherapy







Medicines Management Team







Nurse Triage





Total Nurse Triage






Mind-Active Monitoring






Remote Triage






CRP Point Of Care Testing





Primary Care Pain Management






COVID-19 Impact Service






Atrial Fibrillation (AF)






Urgent Care Innovation
Mental Health Assessment

Urgent Care Innovation
Mental Health Assessment


Increases in the number of primary care contacts relating to low level mental health issues continues to rise. Historically, patients who have required support with their mental health have reached out to their GP as a first point of contact. Under the existing system patients would be given the telephone number of community services at their GP or Triage appointment with the expectation that the patient would then contact the service.


The aim of this innovation was to look to provide a first contact telephone support service for patients presenting to primary care with low level mental health issues.

Patients who are identified as suitable via care coordination, will be referred directly to a link worker for a telephone assessment of their mental health needs and advised of the options and services available to support them.


Enabling this early intervention will mean patients can be signposted to the most appropriate service in the MH pathway avoiding delays resulting from GP appointment waits or second stage triage referral and save GP time where a patient is directly referred to the appropriate service to meet their needs.



Urgent Care Innovation Mental Health Assessment

Urgent Care Innovation TRIAGE


With demand in Primary Care at an all-time high and the additional issues from COVID-19,
in- TRIAGE may need to be capped within practices based on available capacity and this invariably can lead to additional contact with Out of Hours Services (OOH). To try and reduce this burden, we proposed that increasing TRIAGE availability for the cluster at pivotal points over the winter will have added value for patients by increasing the access to primary care, reducing the number of OOH contacts, A&E attendances and/or urgent secondary care referral rates.


The aim of this pilot is to provide additional triage sessions across the cluster. Additional sessions are provided where there is capacity on Mondays and Fridays. With additional in-hours capacity, patients will have increased access to clinical advice and treatment in-hours, with the aim to decrease the number of patients accessing OOH care.



Urgent Care Innovation TRIAGE

Urgent Care Innovation TRIAGE

Urgent Care Innovation Mental Health Assessment






Urgent Care Innovation Triage