The service provides administrative and coordinated support to Hounslow general practices, to enable them to deliver more joined-up proactive and planned care.
Our aim is to organise our staff to enhance and improve on pro-active care, prevention, and self-care for all patients in Hounslow. These patients include those at-risk groups, patients with long-term conditions, over 65’s and those receiving health and social care support from multiple providers.
The GP Support Service has been offered to all 46 Hounslow CCG GP Practices across the five localities of Hounslow, these are Feltham and Bedfont, Great West Road, Hounslow Health, Brentworth and Chiswick. We provide the following support services:
- Work with each GP practice and locality staff to organise monthly Multidisciplinary Team Meetings (MDTs). This includes liaising with community health, mental health, social care, and secondary care staff as required for MDT attendance and participation.
- Provide administrative support for MDT meetings, including planning and reviewing actions for MDT Team members to support the care of the patient.
- Support the effective utilisation of the Whole Systems Integrated Care (WSIC) Dashboard within each practice. Monitoring and reviewing High Intensity User activity in relation to complex patients/those with a care plan.
- Provide support to practices with their call and recall via targets which is included in the OOH, DES and QOF contracts.
- Run and provide regular updates via dashboards (Month of Birth, OOH, DES, QOF).
- To be involved more in the case-finding and coordinating aspects of patient centred care (working towards practice and PCN objectives in a project-based capacity)
- To utilise all methods of patient contact (SMS, phone calls, URLs) to ensure maximum reach and effective numbers of bookings being made.
- To be involved more in the case-finding and coordinating aspects of patient centred care (working towards practice and PCN objectives in a project-based capacity).
- Regular workplan meetings with practices (PM and clinical leads) to understand current needs of practices and support provided to them.
- Support the localities with their Access and Capacity plans which includes promotion, streamlining and actioning PATCHS/Online consultations.
- Working towards and contributing towards digital empowerment of practice/PCN patients.
- Lead and support with Projects, such as Safeguarding audit, document processing, Embedded Digital Champions.
- Support with the reduction of health inequalities by assisting the primary care network with outreach events e.g. healthy hounslow in Feltham and Bedfont, Great West Road events in places of worship and supporting socially isolated patients in Brentworth.
- Continuing cycle of improvement by in-house training in core competencies.
- Providing cross-cover in terms of urgent tasks, dashboards and MDT’s where possible.
This service is not patient facing and does not take referrals. However we are commissioned to work with all practices so please speak to your practice if you would like to find out more about how PCPC supports them.