Transformation Programme Update

Next Quality meeting – 1pm on 7th March 2019 at the Living Waters Church, South Shields

Projects are at various stages – all of which need to be evaluated before November 2019 and where appropriate, recommendations made for applications for continued funding to support successful outcomes.

Practices will be asked to provide certain data to help evaluation and deliver a complete picture in both qualitative and quantitative terms. Practice input is very much valued in this respect as well as anecdotal feedback whilst the projects are ongoing. A quick run through of the story so far:


Programme One – One Stop Breathing Clinics

One Stop Breathing Clinics were set up on a collaborative basis, whereby Pathway practices could refer their patients in for COPD screening. The purpose of this project was to help early identification of people who may potentially have the disease, catching it early enough before so treatments could be expected to be effective. Also for those patients at risk but not yet demonstrating symptoms, health and lifestyle advice is given as preventative measures.

By end of March 2019, 300 appointments will have been made available to patients at the One Stop Breathing Clinics. So far, approximately 13% of patients have been identified with COPD and referred for appropriate treatment.



Programme Two – Compassion in Dying and Advanced Care Planning (ACP)

This programme aims for Advance Care Plans to be put in place for patients, not only those who may be facing decisions due to their illnesses, but ultimately a good idea for everyone to have – a bit like a will.  Research has shown that when people have ACPs in place, there is a reduction of unplanned deaths in hospital and fewer medical interventions in primary care.  ACP provides patients with choices of how they would like their care and their wishes for treatment.

In September 2018, over 20 delegates received Level One Training in Advanced Care Planning from Practices across the patch.  A second cohort of training for level one will be offered in the Spring and it is hoped that more practices will be involved, including nurses and healthcare assistants.

We have two ACP Champions in South Tyneside who will help support adoption of ACP to their own and other practices.    Also a mini session from Compassion in Dying will be given at the Nurses Time Out event in the near future. We are planning communication activities to help remind everyone of this initiative and increase Advanced Care Planning throughout South Tyneside.



Programme Three – Supporting Pharmacy Interventions in Primary Care

GP2Pharmacy is the brand name for this project, developed via discussions with GPs and pharmacists to offer fixed time appointments for patients with a qualified pharmacist, when an appointment with their GP is not essential.  This ultimately frees up GP time and patients can be seen more quickly, with a choice of eventually up to 30 locations, closer to home or their workplace.

Over 8000 appointments will be available between now and September 2019 and pilot practices have already started referring their patients into GP2Pharmacy.

This is an exciting project with great potential and we have had lots of media interest including over 38,000 views of the TV interview on ITV Tyne Tees region as well as national publications such as the Pharmaceutical Journal.   We hope that all practices will ultimately be part of GP2Pharmacy and are already in discussions with the CCG about future funding.  For further information see here.



Programme Four – Childhood Health Workshops

Separate work had already initially taken place at Talbot Medical Centre, designing and delivering workshops to parents and grandparents/carers of children under five. Sixteen practices have signed up to deliver workshops using Talbot’s material and also the transformation project has funded a resus workshop and a pharmacy/minor ailments workshop. Practices are already making reservations with Simon Almond STFT and Louise Lydon of LPC for their workshops – all of which must take place before the end of March 2019 for the funding to be paid to practices.

A reduction in visits to practice and also to A and E can be achieved by increasing the knowledge of parents and carers of under-fives.



Still to come…..

Frailty Project

Practices will soon be invited to take part in this programme, which will involve training for Health Care Assistants to undertake frailty testing and refer to onward pathways as appropriate.


Lifestyle Coaching for patients with mild mental health issues

Expressions of interest are currently invited for this project which will involve First Contact Clinical providing Self Care Coaches to improve behaviour change and self-management for a cohort of patients. The project will address the needs of 258 patients in total and capacity for this project is limited as 25 patients from 10 participating practices can be managed within the pilot.  The health coaches will contact patients identified by the practice and manage the appointments with patients themselves, making appropriate reports back to each practice.


For this issue we have provided an overview of all of the projects. Next time we will look at the progress and share any available statistics to keep you up to date.