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What We Do

In 2008 Tower Hamlets PCT began discussions with all the General Practices in the area about working together to provide care in certain areas. The four practices on the Isle of Dogs started discussions and formed the Healthy Island Partnership – joined at the HIP to improve the health and well-being of all our residents!

The PCT in consultation with a group of clinicians devised ‘care packages’ aimed at improving care in key areas. Your care will still be mostly delivered by your own health care team but in some areas we are offering patients the opportunity to be cared for by a member of another team where they have particular skills. This may mean that you can be seen locally rather than having to travel to a hospital, examples of this in HIP are minor surgery, contraceptive implants and coils and warfarin medication monitoring.

The main difference for practices is that the central team work to help share good practice and improve care across the network. The teams are providing support to each other and participating in multidisciplinary team meetings aimed at increasing our skills and knowledge in areas of care important to the local community.

There are certain targets (some of which are about activities and some of which are about results) which we are measured against both within our network and compared with the other seven networks in Tower Hamlets.

Diabetes

This was the first care package to be developed. The care package is based around a process called the ‘Year of Care’ (you can find more information about the YoC by following this link NHS Diabetes Year of Care).

The Year of Care

We aim to see every patient with type 2 diabetes at least twice a year and more often if there are concerns about blood pressure, cholesterol or levels of glucose. Once a year patients with diabetes will be invited to a care planning consultation. Before this consultation arrangements will be made for a consultation with a health care assistant or nurse where you will have blood pressure measurement, weight check, blood test, possibly a foot check and other routine checks as required. The HCA or nurse will also ask about smoking history, diet and exercise patterns and you can discuss any other issues or concerns you have. Once the results of blood tests are back a letter will be sent to you, this will have details of the results of the tests so that you can see changes in your levels. The letter gives a red/amber/green status to results so that you can see if there are any areas which may be of concern. You will then see a nurse or GP to discuss and plan for the year ahead. We aim to help you plan for any changes you feel necessary and to help you achieve any goals you set. You will be given a written care plan to take away so that you can refer to it in the following months.

Targets

We aim to agree individualised care plans with everyone and your goals may be nothing to do with our ‘readings’ and measurements so it is likely that your targets may not be the same as someone else’s but in general we aim to achieve the following levels

Blood pressure – 140/80 or 130/80 if you have any early eye problems or protein in the urine

Cholesterol – Total Cholesterol < 4mmols/l

HbA1c (the ‘average’ blood sugar) – below 58mmol/mol (this is 7.5% in the ‘old’ measure which many of you may be more familiar with).

Secondary Prevention

This is a newer care package for people who have cardiovascular disease (heart attacks, angina, stroke) but do not have diabetes. We have adopted the Year of Care model for this group of people too (the following link has more information about the The Year of Care Partnership and see the description above).

Targets

As with the diabetes care planning some of your targets may be different but in general we aim to achieve

Blood Pressure – below 140/90

Cholesterol – below 4mmols/l

Hypertension

High blood pressure or Hypertension affects many people and of course there is a wide variation from those with very slightly raised blood pressure requiring annual monitoring and those who require multiple medications. Like diabetes and cardiovascular disease the biggest effect reducing the risk of keeping healthy and reducing the risks from hypertension is lifestyle. Maintaining a healthy weight, reducing salt intake, keeping active and not smoking have more effect than most medications but are not always easy to achieve. The teams are here to try and help you identify ways you can improve your lifestyle. So for people with hypertension we offer a review every six months to check blood pressure and review the other things which affect blood pressure and contribute to your overall risk of cardiovascular disease (there is more information about overall risk in the NHS Health Check section below). You may be asked to attend more frequently if your blood pressure is higher than the target. Again targets main vary for individuals but in general we aim for

Blood Pressure – below 140/90

NHS Health Checks

NHS Health (sometimes known as vascular risk assessments) are being offered to all residents aged 40 – 74 years). Many of you will have received an invitation to attend your practice and we have organised some events offering the checks at health fairs. We also worked with our public health colleagues to offer an evening and Saturday event for a group who frequently don’t come and see us in general practice – working men.

The aim of the Health Check is to help prevent heart disease, stroke, diabetes and kidney disease. The consultation offers the chance to discuss healthy lifestyles with a nurse or highly skilled Health Care Assistant as well as a screening check for blood pressure, weight, waist circumference (an important risk for diabetes) and in some cases a cholesterol test. The information will be entered onto your medical notes and the computer will calculate two scores – a diabetes risk score and a cardiovascular risk score. The nurse or HCA will explain the results carefully with you and you can plan to address any areas of risk. If your overall risk is high you will be offered further blood testing and possibly treatment to reduce risks. Anyone whose risk is high is invited back annually for a review. If your overall risk is low then you will be invited every five years for another NHS Health Check.For more information on NHS Health Checks click on this link NHS Health Check.

COPD

COPD (chronic obstruction pulmonary disease) is a lung condition which causes shortness of breath and wheezing. People with COPD are at more risk from coughs and flu as this can makes the symptoms much more severe. There is currently no cure for COPD but there are treatments which can help with the symptoms. There are also other things which can help keep people with COPD healthy such as influenza and pneumonia vaccinations. The COPD care package offers routine annual reviews for those with mild disease and twice yearly routine reviews for those with more severe disease. It is likely that you will be seen more frequently than this but these reviews should be undertaken when you are well, not when you are having problems with your breathing as this would give us misleading results when you have the spirometry breathing test. We work closely with our colleagues in the Community Respiratory Team and have regular meetings with Dr Simon Lloyd Owen (Respiratory Consultant) to discuss ways in which we can improve care for individuals.

The HIP team have developed a blue bag for people who have frequent exacerbations of COPD. The bag has an instruction label giving details of when to take certain therapies and when to see a GP and is aimed at enabling people to manage their condition and know when to seek early help.

Anticoagulation

People who take a blood thinning drug called warfarin have to attend clinics frequently to check if they are taking the correct dosage of drug. Unfortunately lots of things (food, other medications, alcohol and some environmental factors) interfere with warfarin and so the dosage frequently needs adjusting. Until fairly recently patients had to travel to the Royal London Hospital to get this service. Now all the patients within HIP once they are stable can be seen at one of two sites (Barkantine & Island Health) and see specially trained staff nearer to home.

Long Acting Contraception

Implants and intrauterine methods of contraception (IUD & IUS) have become much more popular in the past few years and one barrier to accessing these has been the lack of local services. Now three of the practices offer this service and any Isle of Dog resident can access the service. Speak to your doctor or nurse for a referral. For more more information about the advantages and disadvantages of all methods of contraception follow the link.

 
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