1. Make BP systolic and diastolic (phase V).

2. Check weight.

3. Check smoking history and alcohol consumption.

4. Offer well Person Clinic appointment if not already attending.

Under 40 years of age.

BP 140/80 follow up appointment in 4 months.

BP between 140/90 and 160/110 - follow up in one month. If 3 readings at this level, medication to be reviewed.

BP over 160/110 - check again in 5 minutes. If still high, medication to be reviewed.

Between 40 - 80.

BP between 160/90 and 200/120, follow up appointment in one month. If f3 readings at this level, medication to be reviewed.

BP over 200/120 - check in 5 minutes. If still high, medication to be reviewed.

1. Use Vamp computer base for age/sex register.

2. Search database for smoking status.

3. Priority groups will include:

a. Diabetes

b. Pregnant women

c. IHD

d. Asthmatics

4. Search database for priority groups.

5. Invite patients to attend surgery to see GP who will give appropriate advice to stop.

Follow up by practice nurse. If unable to stop without further help - use of nicotine

patches and chewing gum. Record on Vamp - smoking status at each attendance.

6. Attached protocol.

7. Audit priority groups.

1. All patients in priority groups should permanently stop smoking.

a. Measure number of smokers in elected groups.

2. Re measure database after 6 months.

HEALTH PROMOTION SUBMISSION - BAND 2.

1. Vamp database for mobidity register.

2. Priority groups:

a. Diabetics

b. Ischaemic Heart Disease

c. FH of IHD or CVA or Hypertension.

3. Practice will identify priority groups from Vamp database opportunistically in surgery,

also from the patients attending Practice Nurse, and from health screening examinations

that have occurred in the last 6 years. Patients will also be given health questionnaires

when they attend surgery for whatever reason. All these results will be fed into the Vamp

database.

4. Patients with hypertension will be called to attend nurse run BP clinic if they have not

had a BP recorded in the last 6 months. Patients attending BP clinic will be given

appointment to re-attend clinic, and if they do not attend will be sent a reminder.

5. Patients with stable mild or asymptomatic IHD will be called annually to see a doctor to

review medication, BP, dietary advice, smoking status, weight and if appropriate

cholesterol.

6. Patients with symptomatic or unstable IHD will be attending GP anyway.

7. Patients with stroke will be called annually to see practice nurse for assessment of

physical, psychological and social need. In addition they will have BP, weight, urinalysis,

smoking status recorded, dietary advice given if appropriate. Referral to other agencies

could be initiated if required e.g. social services, community nurses, chiropody,

occupational therapy.

8. BP will be recorded on the Vamp database.

9. Non attenders will be identified using Vamp and will be invited to attend by letter.

10. The uptake of these services will be audited using the Vamp database.

11. The staff involved will be doctors, practice nurse, and computer operators and practice

manager. A continuing education programme for all staff involved will continue.

12. Other agencies will be involved where required.

C D M - A s t h m a

The asthma register is on the Vamp database. Patients are already being written to with an

indication to attend clinic, and non attenders are sent further appointments.

Details of care are set out in the attached protocol. Audit will be carried out in consultation

with Gwent MAAG.

Practice nurses have attended the courses run by the asthma training centre in Stratford-upon-

Avon.

P R O T O CO L F O R A S T H M A C L I N I C

AIM To monitor and improve the condition of asthmatic patients,

To invite patients on combined therapy and supply the notes for each clinic. Follow up appointments decided during consultation, depending on severity of the condition.

Dr. Statham and practice nurses.

To take 30 minutes for:

a. History; Family History, Trigger factors, Disturbed nights, Absence from work or school,

Reduced ability to work or exercise.

b. Observations; Height and weight (on centile charts for children), Blood pressure (for

adults), Peak flow rate, Forced expiratory volume, Forced vital capacity.

c. Education of patient and family. For first aid, brief description of asthma and give leaflets

which explain more fully.

d. Demonstration of use of inhaler and peak flow meter. Ask patient to keep a chart of peak

flow measurements until next visit.

To prescribe and review medication.

Follow up appointments.

Record height and weight for children, blood pressure for adults, PFR, before and after inhaler

(check inhaler technique), FEV, FVC.

Discuss how well condition has been controlled since previous visit.

Gradually work through education check list:

1. Condition physical, not psychological

2. How to recognise deterioration in condition

3. How to deal with deterioration

4. Action and timing of inhaler

5. Possible trigger factors

Fears and anxieties

a. No smoking - if appropriate suggest 'Quit smoking' support group

b. Regular exercise, using inhaler first if asthma is exercise induced.

Work out with patient and family Self Management plan (early intervention) e.g.

Individual management plans will be provided for patients.

- Best peak flow rate or expected PFR if stated

- At 80% of best PFR - double inhaled steroid

- At 50% of best PFR - start oral steroids

- At 30% of best PFR - call doctor.

This is for guidance only - individual plans will be tailored to suit individual patients.

HEALTH PROMOTION SUBMISSION - BAND 3

The practice morbidity register is held in the Vamp database.

Priority groups will include those patients with a first degree relative with a history of IHD and CVA occurring under the age of 60. First degree relatives of patients with hyperlipidaemia and those with a BMI of over 30.

The priority groups will be identified from the existing Vamp database and opportunistically in surgery and practice nurse run clinics. We will also use information gained from out-patients and in-patients discharges, the Heart Beat Wales Campaign. Occupational health programmes and private medical care screening programmes who send reports to the surgery.

Hypertension See attached protocol - call and recall systems described in application for

band 2.

IHD See attached protocol - call and recall systems described in application for

band 2.

CVA See attached protocol - call and recall systems described in application for

band 2.

Information from BP, smoking, family history, BMI, alcohol, exercise and diet will be recorded on the Vamp database. Patients without recorded information after searching through any written notes will be written to and sent a health questionnaire requesting the relevant information which will then be entered on the Vamp database.

The practice will measure what proportion of the target population has had the relevant information recorded using the guidelines provided by the Welsh Office and FHSA using the Vamp computer system.

The doctors, practice nurses, computer operators, practice manager, and reception staff, all will be involved in a continuing education programme described in the annual report. The care will be provided both in surgery and clinics e.g. hypertension, diabetic and well person clinic.

Audit will be carried out in consultation with Gwent MAAG using agreed protocol.

PROTOCOL OF CARE FOR PATIENTS WITH CVA

Morbidity register will be searched using the Vamp database.

Patients will be called to attend clinic or surgery at least annually.

Risk factors will be recorded i.e. smoking, diet, exercise and alcohol consumption.

Physical disability if any will be a recorded assessment of need for any physical aide e.g. zimmer frame, bath sear, tap aid, etc will be made and appropriate referral made.

BP, weight, height if necessary will be recorded.

Any advice re diet, exercise, alcohol consumption and weight will be given. BP will be acted upon in accordance with hypertension protocol.

PROTOCOL OF CARE OF PATIENTS WITH IHD

Patients with IHD will be recorded on the Vamp database and will be called or recalled at least annually.

The aim is to minimise their symptoms and maximise their potential through lifestyle and medical intervention.

A history of smoking, alcohol consumption, severity of chest pain dyspndea and fatigue will be assessed using a scale of 0 to 4 (asymptomatic to severe symptoms). Dietary, exercise history will be obtained.

BP, weight, urine for glucose and cholesterol (if indicated) will be checked at each visit. Advice will be given with regard to smoking, diet and exercise where appropriate.

If necessary patients will see a doctor to adjust medication or consider referral for further investigation if appropriate according to good clinical practice.

All the above information will be recorded on the Vamp database where appropriate.

CDM - DIABETES

Diabetics are identified from the disease register off the Vamp database.

Over 70% of patients already attend the surgery clinic and a recall system operated for non attenders. Any further non attenders will be written to inviting them to attend the diabetic clinic.

Newly diagnosed patients are educated as to the nature of diabetes and its possible complications. the importance of dietary control is stressed and a referral is made to the local dietician service and chiropody if appropriate. Patients are encouraged to join the BDA to help provide a continuing education service.

Patients are managed guided by the attached practice protocol. Clinics are run jointly by practice nurses and Dr's Gray and Statham. The nurses qualifications are as follows:

D. Hayes SRN

A. Rees SRN

R. Fellows SRN

L. Bolton SRN

All nurses have attended specialist courses and study days in diabetes management

There will be a continuing programme of education. Nurses attend the diabetes special interest group meeting and any relevant training courses.

Audit will be carried out in conjunction with Gwent MAAG.

Insulin dependant diabetics may also attend hospital run clinic.

PROTOCOL FOR DIABETES

Symptoms Polyuria, Polydipsia, Weight loss.

Asymptomatic Glycosuria.

Random plasma glucose > 8.5

Fasting plasma glucose > 6.5

GTT

Diet and weight loss if necessary.

Refer to Dieticians.

Oral hypoglycaemics if control by diet is unsatisfactory.

IF OBESE - Metformin 500mg tds increasing to maximum 850mg bd.

plus/minus Sulphonyl urea as below.

Over 70 - Glicazide 40mg to maximum 160mg bd.

Under 70 - Glibenclamide 2.5mg to 10mg bd.

plus/minus Metformin as above.

If control still difficult refer for consideration of Insulin.

NURSE - Measure weight

B.P.

V.A.

B.S.

Urine

DOCTOR

Aim for - Blood glucose 5-9

HBAIC < 10

Cholesterol < 6

Fasting glucose is a good indicator of control.

Check fundi through dilated pupils. Refer if perimacular changes or extensive background retinopathy, neovascularisation or unexplained reduction in visual acuity.

Check feet, pulses, vibration sense/proprioception, fungal infection, nail cutting - refer for chiropody if necessary.

Under 40 years aim for < 140/90

40 - 80 years aim for 160/90

Over 80 years ? evidence

Use Bendrofluazidee 2.5mg om plus/minus Ace inhibitor.