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

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Knowing that what you do works is vital in providing effective healthcare. 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 services .

Clinical Outcomes coordinator

Acute Physiotherapy

Musculoskeletal problems make up around 30% of GP`s workload. Most of these cases can be managed most effectively by a physiotherapist. Red Kite has 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. 68% of patients have been discharged from the service with no requirement for a GP appointment.

In 2015 Red Kite introduced the role of the Pharmacy team in to the South Powys Practices. The team now consists of 4 Pharmacy technicians and 5 Pharmacists working from within the practices on a day to day basis. 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. They continually monitor drug use to optimise savings and are an integral part of the triage systems within the practices. 3 of the Pharmacists have undertaken their Independent Prescribing course which will allow them to prescribe certain medications to patients within their specialist areas. To date the team have been responsible for achieving over £860,000 of prescribing savings across the cluster.

Medicines Management Team

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 of the outcomes showed that a large proportion of the ailments being seen could be effectively treated through triage and effective use of all health services, therefore, reducing waiting times and improving access and treatments for patients who are acutely unwell. All four practices introduced a telephone first approach to handle these requests. 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. Through building close relationships with health care providers, they are able to refer in to the Pharmacy team, Community Pharmacy, Optician, Active Monitoring and a range of other services. This ensures the patient receives advice and treatment in a timely and effective manner by the most appropriate service. Statistics show that, on average, 68% of patients requesting on the day appointments do not require a GP appointment with a further 18% requiring advice only. The practices currently have Nurses in South Powys enrolled on minor illness courses and 2 have undertaken the Independent Prescribing degree course providing face to face direct patient care.

Nurse Triage

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, and that access was improved for all patients. 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 co-morbidity and complex patients. Patients receive continuity of care by being followed up by the same practitioner, and it has allowed the highly trained Practice Nurses to enhance and extend their skills and roles within the team. 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 40% of patients requesting a routine appointment have been signposted to other appropriate services. 13% of patients require advice only notably, 7.38% (99 patients) 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.

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 Healthboard who now use this alongside silvercloud as an online CBT program.

Mind-Active Monitoring

Remote Triage

As part of our extended services, the Haygarth practice has been able to offer and extend the triage service to include a trial of remote triage. Triage Nurses based in the practice, are 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 has been successfully trialled and relieved pressure on clinical staff, allowing us to streamline services and ensure that patient services are not interrupted.

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.

Our Services

Clinical Outcomes coordinator







Acute Physiotherapy







Medicines Management Team







Nurse Triage





Total Nurse Triage






Mind-Active Monitoring






Remote Triage






CRP Point Of Care Testing





Pharmaceutical Team Activity Unscheduled Triage Report Scheduled Triage Report Remote Triage Report Acute Physiotherapy Report