The following updates are provided by Hauora Tairāwhiti GP liaison Anna Meuli. Anna works 0.2FTE in this role (Thursday and Friday mornings) and can be contacted at firstname.lastname@example.org.
Hospital is over capacity
Currently the hospital is full and overflowing. Could you be aware of this when sending referrals, and consider phoning the relevant specialist for advice if you feel there is an option of safely managing your patient in the community. Primary options actute care is available to support this.
The Emergency Department particularly requests you consider all referrals and what can be managed safely in primary care. Please do not send patients with a set expectation of the investigation or treatment they should receive as this is difficult for them to manage when their own assessment and treatment plan may differ. Please communicate the need for further assessment and management as deemed appropriate by the hospital staff.
The orthopaedic service has been significantly understaffed for some time, this has affected many patients who have not been able to access much needed services. The department thanks you for the extra work you have put into managing these patients. They are now pleased to share that they have sufficient staffing to enable a catch up project to begin, and planning around how best to make the service sustainable and accessible for those who need it most in the future.
Current permanent orthopaedic surgeons are: Kobus Van Aswegen (HOD), Greg Alexander, Peter Birch (starting November), Duncan Cundall-Curry (starting February). Current locums are: Ramez Ailabouni (unconfirmed end date), Prieur Du Plessis (unconfirmed end date), Chris Phoon (finishing in December), Neal Singleton (Dec-Jan).
Currently, there is a back log of around 1,200 patients. Approximately 600 of these are awaiting first assessment and the remainder are follow ups. There has been a lot of work done on catching up the operative lists. The challenge is to appropriately prioritise those on waiting lists to ensure those needing to be seen most urgently are. To enable this, a nurse practitioner, Amelia Howard-Hill, has been employed until the end of January. Amelia has worked with the Canterbury orthopaedic department in the past and has a lot of clinical orthopaedic experience. She is reviewing all waiting list referrals, and implementing a phone triage system for all patients to determine the highest priority. This is based on NZ Orthopaedic Association Best Practice guidelines. Phone triaging has begun.
You and the patient will receive a letter to identify their priority. Some will be seen directly by an orthopaedic surgeon, some by Amelia, and some who are identified as no longer needing specialist service returned to their GP. All of these cases will get a letter outlining current issues and suggested management in the community if this is deemed more appropriate.
Even with increased staffing levels, this is a large back log to catch up. If you identify patients who no longer require assessment, or who have an increased urgency since they were last referred, identifying these by BPAC e-referral would help the process.
Moving forward, to enable the team to sustain a responsive service, referrals that don't provide sufficient information to adequately triage the referral will be returned. Please remember to provide good detail about the condition, clinical examination findings, nature duration and impact of pain, effect on person's life and function, management trialled to date, and include appropriate imaging. Any referrals declined will include information to assist with management and guidance for when re-referral is appropriate.
Johan Peters (medical director for surgical services), Amelia and myself would like to talk directly with your practice to further discuss the process and any input you have for this. Please contact me to let me know a time that suits.
RNZCGP education evening and first local faculty meeting 22 November- How will Technology change general practice? (6pm at 3 Rivers)
Members of the RNZCGP should have received an invitation directly from the College. All (including non-members) are welcome to attend, you can RSVP to me directly if easier. Drinks from 6pm, talk 6.30pm followed by our first subfaculty meeting to confirm we want to reinstate our subfaculty and how we want to spend the funding available to us. Aiming to be fished by 8pm. Blurb as below.
'Arturo Pelayo lends his expertise as an innovation strategist. This role has him working with organisations in Germany, the USA, Mexico and New Zealand, helping them to meet the challenges of unstoppable change in a positive and proactive manner. In his presentation, Arturo will consider how technology is changing general practice and the primary health care sector, identifying opportunities and barriers, and developing a mandate for change. Attendees will no doubt enjoy discussing the potential and scope for innovation in general practice and primary health care with Arturo.'
Letter from the physiotherapy department regarding their backlog of referrals and how they are planning to manage this moving forward. Please note this means GP referrals are restricted to certain criteria as outlined. Happy to receive any feedback around this.
Following feedback from a few GPs about their frustration with the new service specific sleep referrals and level of information needed for these, I met with Michelle Scott, sleep nurse, to further discuss their service and the form. Locally sleep disordered breathing is a nurse led service with support from Andy Veale, respiratory/ sleep physician on a visiting basis. There are 650 people in our district on CPAP or BiPAP and they receive on average 25-30 new referrals/month. They were finding many referrals contained little information, including no Epworth score or occupational information that helped them triage the urgency of the referral. Sleep services across the region (and nationwide) were facing similar issues.
Waikato has developed the form to gather the information they needed and it made a huge difference to their ability to respond to referrals appropriately, hence the form being adopted here and in other DHBs. Michelle understands that especially when first completing the form after the patient leaving your office, you may not have collected all relevant information (eg neck circumference). If this is the case, you can enter a zero value and still submit the form. She won't decline them. Hopefully over time it will prompt best practice issues to consider when assessing someone for sleep disordered breathing.
The inclusion of an ENT exam is to highlight any obstructive issues that may be amenable to ENT intervention. If the patient has large tonsils and a BMI < 35 a concurrent referral to ENT to consider tonsillectomy should be considered. Dr Avisenis has been involved in developing these criteria. The inclusion of TSH and HbA1C is to exclude reversible cause of tiredness and screen for comorbid metabolic issues - I'm afraid I've tested and these can't be zero valued as your form won't send without a number - you may need to park it while awaiting results and then resubmit.
I know these forms are frustrating and feel like extra work, hopefully they ensure our patients get best possible care and appropriate response to referral. Unfortunately many secondary services, like primary care services, are feeling pressure and need to find ways to most appropriately respond to the demand.
Te Kuwatawata panui
October panui from Te Kuwatawata. There is ongoing review of GP input into, and feedback about, Te Kuwatawata. Thank you to those who recently attended a workshop to talk through some of these issues. GPs do so much work in mental health and need to work closely with those who provide the higher level support some of our patients need to make sure we are all working together to have the right supports in place locally. The evaluation team are putting together a survey to gauge wider GP feedback- I will send you the link when it comes to me. Can I also check you are all now receiving clinical care forms back in response to all referrals into Te Kuwatawata?
Lynne Gray, oncology community nurse specialist (CNS) has just achieved nurse practitioner status. This means she now has prescribing rights and will do this with mentoring oversight from the Waikato Oncologists.
Jackie Clapperton (Ambulance and Primary Care) and Kylie Morrissey (Aged Residential Care and Primary Care) are also nurse practitioners with prescribing rights.
Tracy Low and Kristen Willock, cardiology CNSs are able to prescribe in their scope of practice and are working with the new cardiologists to do this with their support.
Lisa Smith and Kim Cameron diabetes CNSs are able to prescribe in their scope of practice and are working with Dr Joanna to provide oversight.
All nurse prescribers meet with Chris Duffy and Martin Kennedy (pharmacist) on a regular basis to have prescribing review and oversight.
Congratulations to all of these nurses on their achievement and they are keen to work closely with GPs to provide best care for our patients. The Tui Te Ora nurses will communicate any medication changes via clinical care forms, and if you have any feedback or want to discuss anything please feel free to phone them. I'm sure they will appreciate GP support.
Diabetes CNS service
I met Lisa Smith and Kim Cameron, diabetes CNSs to discuss their service. They have noticed a large increase in women with diabetes in pregnancy, probably a result of both increasing incidence and reflecting increased screening. They are also finding that they have many Type 1 and 2 diabetics with unplanned pregnancies. They ask if we can continue to monitor gestational diabetics with a yearly HbA1C post pregnancy (to monitor for progression to type 2 diabetes), and to continue to be mindful of discussing pregnancy planning and contraception, including options of long acting reversible contraception, with all diabetic women of child bearing age.
For insulin starts in Type 2 diabetics, they would like to remind you funding is available through primary options acute care to support this in primary care. They are happy to offer any support or education you or your practice nurses need to provide this.
Prostate cancer exercise programme
Cancer Society in partnership with Sport Gisborne Tairāwhiti and with input from the DHB physiotherapy and oncology team have developed an exercise programme for men with prostate cancer. They have two years of preliminary funding to run this programme. The programme will be led by a clinical exercise physiologist, Caleb Milne and Steve Allan from Sport Gisborne. As you probably know there is increasing evidence to show exercise is beneficial for both physical and psychological wellbeing in cancer patients, and it is hoped that exercise programmes could be extended to people with other diagnoses if this project is successful.
The prostate cancer group was chosen as they are a relatively large group, and men in general do not access the Cancer Society and its support services as well as some other cancer groups do. Any man with prostate cancer is eligible for the programme. Each client will have their own unique exercise programme to follow, whilst training in a group environment. These programmes, along with careful physical monitoring during training sessions will be in accordance with current exercise prescription guidelines. It is hoped the group format will also provide an informal support group.
A pilot group will start in November then will open out to all referrers. The physiologist will undertake a thorough fitness assessment prior to the programme starting and only ask for medical clearance if there are any concerning comorbidities. You will be notified of any patients entering or exiting the programme. If you have any questions or someone who is keen to enrol in the programme please contact Caleb at email@example.com for the appropriate referral form. We are hoping e-referral will be an option in the future.
Children's Team and children's health broker- Aimee Milne 021 853 409
I met with Aimee Milne, children's health broker to discuss her role and how she can work with GPs. Aimee comes from a nursing background and has spent the last six months establishing a new role as the children's health broker. She works closely with the Children's Team, Gateway assessment service, and many other services. The Children's Team receive referrals from health, social and education services about children who have been identified as having complex medical or social needs.
The team meet weekly to discuss referrals and identify the best support services for these children and their whānau. In the Children's Team is Aimee, a WINZ representative, a financial support person, a corrections representative, and then a review panel consisting of Mary Stonehouse (paediatrician), a drug and alcohol specialist, and an education representative. They have close contact with Oranga Tamariki and Police and work with escalating cases to these services if needed.
Aimee initially gathers information from all services in town the whānau may be involved with in order to get a clearer picture of what is happening with the child, then the panel is able to make a recommendation on support needed. Since her role started six months ago the team has gone from receiving 1-2 referrals/week to around 10 referrals/week. She feels she makes a real difference for these children in terms of linking all the information and services that are out there into a cohesive support team. The aim is to keep children safe and at the centre of any care plan.
No referrals have come from primary care yet, as I suspect most GPs and practice nurses are unaware of the availability of this valuable role. Aimee is happy to receive phone calls if you have concerns about a child or whānau, and is able to share information under the Vulnerable Children's Act. Formal referrals need to be made via the Children's Team, these require written permission from the whānau. See the Manaaki tamariki referral form. We are looking into whether this can be developed into a service specific BPAC e-referral.
Note there is a section requesting which service you think is most appropriate for the child. I have included a brief summary of what each provides, but representatives from each service are involved at the weekly reviews of referrals so can triage appropriately at that stage so long as you clearly identify the issues and needs for the whānau.
Rangatahi Gender variance policy
June Cumberland, who works locally as a youth health nurse in schools, has done a project to clarify supports available for young people who are transgender. She has put together a pack of resources to bring to each GP clinic, and is keen to identify a GP at each clinic comfortable seeing young people with transgender issues so their names can be shared with this community. She may have contacted some of you directly, if you wish to be included on this list or learn more please get in touch with her: firstname.lastname@example.org.
She has created a policy for youth with gender diversity. On page 5 there is a pathway summary for referral services. In short- if someone is over 16 years they can be referred to the Community Clinic. If someone is under 16 years, they can be referred via CAMHS, or the crisis team if there is an urgent need. Once they have had psychological assessment and support they will be referred to Mary Stonehouse paediatrician if they are wanting to pursue hormonal treatment options. I have also attached a June has put together a document for GPs outlining useful resources.
Huntingtons disease advisor
Jocelyn Pack is available to support families affected by Huntingtons disease, and raise general awareness of the disorder. Please see this information about all the services she is able to provide and her contact details.