Our patient population

Patients over 75 may have additional needs that we aim to support and provide the best possible care to ensure good quality and quantity of life. There are a number of approaches that we continue to work on to enable this.

Equal access to appointments

• We encourage all of our patients to use E consultations and support all ages to be able to do this. We do recognise that not everyone is IT literate so we will take requests over the phone or by walking in while providing equal access to the appointments.
• Our care coordinators are trained to use a similar data gathering tool so the patient’s care needs are identified.

Housebound patients

• Our nursing team can visit patients to take bloods and carry out some long-term reviews.
• We work closely with our district nursing team for long-term support in the community as well as our urgent care response team who help in the more acute setting. We also work alongside our hospital at home team to try and avoid unnecessary admissions to hospital.
• We also have regular routine home visit slots to see patients who may have chronic complex health needs who would benefit from a GP assessment at home.

End of life care

• We work with our community palliative care team for both proactive care planning and end of life support.
• The practice also engages with the new HELPSS service which supports patients making decisions about future care.

Frailty

• We use national tools to identify our most frail patients and have a register to ensure we can easily identify those who would benefit from additional support.
• The practice is proud to have our complex and frail list which is where we can identify those patients most in need and who would benefit from continuity of care with a named GP.
  Nominated care coordinator to support with vulnerable
• The practice has employed a specially trained care coordinator who helps support on more vulnerable patients. She will often help troubleshoot and coordinate care between the different organisations.

Dementia support

• Strayside has a dedicated Dementia coordinator who can see and assess patients with memory concerns and works alongside the local Memory Clinic as well as Dementia Forward to help support both patients and their family.

Accessible building

• We are proud to be working within a modern health building with good access for patients. We have disabled parking, lifts, hearing loops and accessible toilets.

Care home links

• For over 15 years we have had very close links with the local care homes that we look after. We led on an area wide project having a dedicated care homes linked to each practice and having nominated GP leads. This proceeded the national drive to do this.
• We look after three main care homes for the elderly which include Apley Grange, Harcourt Gardens and Grosvenor House.

Managing long-term conditions is part of our core work using all members of the multidisciplinary team. By enabling high quality long-term care, we can ensure we are aiming to optimise patient’s quality of life.

Long-term reviews

• We offer annual reviews in patients’ birth month. We will send you an invite to have tests done in advance then see our highly trained nurses or other members of the team.
• Our Pharmacy team manage a number of conditions including blood pressure, complex medication reviews, thyroid disease, polymyalgia Rheumatica, osteoporosis and blood thinning medication monitoring.

Medication reviews

• The practice has systems in place to ensure we monitor your medications regularly.
• We will sometimes send out questionnaires to fill in but also may book you in with our clinical pharmacists where a more detailed review is required.
• Patients can also request a medication review. We will particularly target patients who are on more than 10 drugs or on drugs of addiction.
• Patients on certain drugs (Amber drugs) may need frequent blood testing and we work closely with consultants at the hospital to manage this.

Complex wounds

• Our practice nurses follow national guidance and manage complex wounds at the practice.
• We have proudly created protocols and documents to offer high quality care which has been recognised by our local hospital.
• This has meant that our wound management is gold standard treatment.

We are dedicated to providing high quality care to our families and young people. We enjoy developing these relationships over many years and build on trust and support especially for those with more complex needs.

Access to appointment

• We encourage the whole family to be registered at Strayside Health so we have a better understanding of your whole family’s needs.
• The practice uses systems to highlight those people who are more vulnerable and need additional support.

Routine vaccinations

• At Strayside, we work hard to ensure all children are offered vaccinations and ensure we support those who have not yet attended.
• Our high vaccination rate reflects the effort we put into this.

Postnatal checks and baby checks

• Our team offer separate routine appointments for postnatal mums (around 6 weeks) as well as their babies (at 8 weeks, usually linked with their first immunisations).
• This is an important part of the service to ensure families are getting the support they need and gives an opportunity to discuss any concerns or worries they might have.
• We work closely with our health visitors and midwives to provide this support as well.

Maternity care

• Community midwives work within our practice and see and support our pregnant women throughout their pregnancy.
• We work closely with them and support where there are more complex needs involved.

Safeguarding

• This is an important part of all aspects of healthcare to ensure that our families and young people are supported and are safe.
• We have a dedicated team who support any patient or family who is in need.
• We have a strong ethos to support families whatever the problem. We never judge our patients and want you to feel able to come and discuss your worries or concerns with us.
• We have designed a tool to look for patients who are at risk of missing appointments and contact every single one of those patients to support them in their attendance to reduce the risks of missed appointments and potential harm.

We support all adults from 18 to 74 years old to ensure a healthy life.

Access to appointments

• Appointment booking links are usually sent by text message or email to allow patients choice to choose when they can attend.
• We work alongside our enhanced access service which offers appointments early and late during weekdays and on Saturdays and Bank Holidays.
• We have been using a total triage digital model for a number of years which allows patients to easily send E consultations to the practice during our working hours.

Communication

• We use a range of methods to communicate with our patients which includes email, mobile phone, telephone calls and social media.
• We have active social media platforms including Facebook and Instagram

Screening

• We encourage cervical screening and use our enhanced access so working patients can attend more easily.
• We pay a lot of attention to our NHS health check programme. We send out multiple invites to our patients and offer them both at weekends and during the week with an aim to improve long term wellbeing.

Self-referral for appointments

• We have a number of different teams where our patients can directly self-refer. This includes:
  • First contact practitioners (physios)
  • Pharmacy first
  • Tier two weight management programmes
  • NHS talking therapies for low level mental health problems

Veteran friendly accredited practice

• We are a veteran friendly practice and ensure that all our team are aware of how we can support our veterans.

This can affect many of our patients in different ways and not everyone always realises they may be in this group.

Translation services

• We have full access to translation services to help those who struggle with English as a primary language or require British Sign Language translation.
• It is helpful if we have advanced notice so we can book it in and allow enough time for the appointment.

Homeless patients

• The practice will always register any patient even if they do not have a fixed address.
• We work closely with our local home services to support patients who may have more complex needs.

Care coordination for our vulnerable patients

• Our specialist care coordinator helps support our patients who may struggle to get to appointments. She develops a relationship with our most vulnerable patients to support them and ensure they can access health care when needed.

Complex and frail system

• Those patients who may have more complex health issues, we can help identify and offer a more person-centred approach with named GPs where needed.

Support from our wider team

• We recognise that are more vulnerable patients may benefit from the wider team. This may include support from our social prescribers, learning difficulty support teams, safeguarding team and alcohol and drug abuse teams (where appropriate).

Reasonable Adjustments

• The practice recognises the importance of offering reasonable adjustments where we can. We document these on the national system with your consent and ensure we aim to meet these.

Working with our community teams

• The practice opportunistically attends fortnightly meetings with our multidisciplinary team called the HARA team.
• This gives us an opportunity to discuss more complex cases and have a shared approach to support the best possible care for those individuals.

Unfortunately, many patients now suffer with mental health difficulties, and we are living in a society where we hope stigma has gone and patients feel able to come and discuss their mental health concerns with health professionals. We recognise there is some unmet need in the community and at times some challenges accessing the mental health support.

Mental health practitioners

• Over the last 3 years we have recruited two of our own mental health practitioners who see large numbers of our patients and can be directly accessed.
• We are proud of the high-quality service that these professionals can offer and the feedback from patients has been overwhelmingly positive.

Dementia Support worker

• We have our own dementia coordinator who works in the practice regularly to offer appointments both for patients and their families.
• He can offer support and help with increasing diagnosis rates.

Severe mental illness champions

• At the practice, we have our own mental health champions who look to support patients and help support their rights to access to care.
• We have robust systems in place to invite all our eligible patients for a yearly review to ensure they have all their different health needs addressed and offered support where appropriate.

Screening support

• We understand that patients with mental health illness are at increased risks of poor health long-term.
• We have therefore taken part in the cancer prevention incentive plan to try and target those patients most at risk and support them in attending for screening.
• Longer term we hope this will mean reduced rates of cancer diagnosis at later stages in those most vulnerable.