Astley General Practice

As part of the GP Contract, all patients registered at a GP practice are allocated an Accountable GP.

What does “accountable mean”?The named GP is largely a role of oversight. It reassures patients they have one GP who is responsible for their care.

However it is important to note:

- Patients do not need to see their named GP when they book an appointment with the practice.

- Patients are entitled to choose to see any GP or nurse in the practice.

- The named GP works with relevant health and social care professionals to deliver a multi-disciplinary care package that meets the needs of the patient.

- The named GP will not take on 24 hour responsibility for the patient, or have to change their working hours.

These staff members play a crucial role in helping patients get the right support at the right time to manage a wide range of needs. Care navigators are part of the multi-disciplinary team and help to identify and signpost people to available services, acting as a link between the patient and the clinical staff. Their job is to direct patients to the best clinician for their condition which may not be always be a GP.

A GP is usually the primary clinician who treats a patient with a physical or mental health concern. While GPs are available in our practice daily, they are also part of a much broader clinical team which handles patient treatments. GPs work as part of a large multidisciplinary team that supports the holistic, all-around care of the patient. This can include practice nurses, pharmacists, emergency care practitioners, and healthcare assistants. GPs treat all common medical conditions and refer patients to hospitals and other medical services for urgent and specialist treatment.

GPs focus on the health of the whole person, combining physical, psychological, and social aspects of care. Some of our GPs specialise in certain medical conditions, and patients may be referred to these specialised GPs for treatment.

GP Assistants provide a support role, carrying out administrative tasks, combined in some areas with basic clinical duties. They can help to free up GPs time and contribute to the smooth running of appointments, improving patients experience in the surgery.

ANPs are medically trained to treat patients and prescribe for them. ANPs are educated to masters level in advanced practice and assessed as competent, using expert knowledge and skills. They have the freedom and authority to act, making autonomous decisions in assessing, diagnosing, and treating patients. ANPs develop close relationships with their patients and work in partnership with them to achieve their best health.

ANPs also make their own decisions on the assessment, diagnosis and interpretation of test results. They can independently prescribe appropriate medication and evaluate or refer to other specialists if necessary. ANPs liaise closely with GPs in practice.

Practice nurses work in GP surgeries as part of the primary healthcare team. The practice nurse looks after a whole spectrum of patient care, from managing chronic diseases to health screening, for example, cytology (smear tests), to immunisations, including flu, pneumococcal, and those needed for babies. They carry out a wide range of roles allowing them to develop long-term relationships with individuals and families to better manage their conditions and improve patients’ physical and mental health and wellbeing.

First Contact Practitioners/MSK provide expert advice and treatment for patients' condition, illness or disability. They may share exercises to reduce pain and discomfort, and improve the movement or refer a patient to the specialist service.

Assistant Practitioners and HCAs have an important role in general practice, providing valuable assistance to GPs and practice nurses. Our HCAs are trained to carry out care of patients independently, in line with their qualifications and competencies, with access to a Practice Nurse or GP for support when necessary. HCAs look after chronic disease reviews, such as for hypertension (blood pressure), and give new patients health screening.

Physician Associates work alongside GPs to assess patients, diagnose health concerns, support those with long-term conditions and provide advice on how to stay healthy and well.

Mental Health and Wellbeing Practitioners (MHWPs) provide evidence-based interventions and co-ordinate care plans for adults with mental health problems. Based in the community, they play an important role in supporting adults of all ages to live fulfilling lives. They do not provide psychological therapy but deliver effective wellbeing interventions to help people recover and improve their lives.

Pharmacists play a significant part in the management of medicines in primary care. They have a strategic role that focuses on maximising benefits and minimising risks associated with medicines, as well as making the best use of resources allocated for medication. Our pharmacists are either prescribers or training to become prescribers and will take responsibility for some aspects of care management of patients with chronic diseases, including undertaking clinical medication reviews to proactively manage patients and their care.

The practice manager will coordinate and organise fundamental aspects of practice functionality including the appointments calendar, patient services, staff rotas, health and safety management, and communications with other practices in the SSP group. Practice Managers act as the central hub of administration throughout the practice as a whole. Assistant Practice Managers support practice managers in all necessary internal operations.

The ECP is a new and developing role in general practice. Our ECPs work autonomously and can triage patients, advise on general healthcare, and promote self-management of health to patients. They can treat and prescribe to patients within the scope of their remit. ECPs can provide appropriate treatment, diagnostics, care and support.

Social Prescribers talk to patients about what matters to them and what support they may need to feel happier and healthier. They are trained in what is available in the community and connect people to local groups, activities and services that make a lasting difference.

Care Co-ordinators help make sure things run as smoothly as possible for patients with long-term health conditions, particularly those who receive care from many different health services.

These are dedicated staff in surgeries that provide support and assistance within their defined categories, including palliative care, dementia, or general care. The list of Champions is displayed in practice with further details on the roles. The different Champions are as follows.

Learning disabilities: a dedicated champion specialising in caring for our patients with learning disabilities. The register is monitored to ensure patients are reviewed regularly.

Palliative care/end-of-life: a dedicated champion for palliative care and end-of-life who supports patients coming to the end of their lives and families facing the loss of a loved one.

Carers: a dedicated carers’ champion who offers advice and support to those looking after someone who cannot care for themselves. Regular contact is maintained with the local carers centre and patients to ensure appropriate services and support are in place.

Cancer: a dedicated cancer champion who contacts all newly diagnosed patients to ensure they have all systems and processes in place for their follow-up and medication. They also offer general support.

Long-term conditions: a dedicated champion to support compliance with annual reviews, which means better control of long-term conditions and better quality of life for our patients. Extra-long appointments offer convenience and reduce time off work because all conditions are reviewed together at one appointment.

Cytology: a dedicated champion to support compliance with the implementation of cervical smears within a practice based on government and NHSE guidelines.

Mental health and mental wellbeing: a dedicated champion to support patients with mental health and mental wellbeing concerns. Regular contact is maintained, and patients are aware that support is available to signpost to appropriate services and provide advice as required.

Dementia: a dedicated champion to support patients with dementia and their families. Regular contact is maintained to provide support and signpost patients to other services.

DOLS: a dedicated champion to support the practice with Deprivation of Liberty Safeguards (DOLS) related queries/concerns.

Military veterans: a dedicated champion to support the practice in liaising with military veterans and serving/service personnel. Regular contact is maintained, and patients are aware of the champion who can signpost to appropriate services and provide support as required.

Sepsis: a dedicated champion to support patients who have had a sepsis diagnosis to ensure appropriate services and support are in place. A register is monitored to ensure correct clinical pathways are followed and learning points are shared.

Patient liaison officer: a dedicated champion to promote services offered by the practice to new and existing patients and obtain feedback. Regular contact is made with existing PPG members, and promotions are sent out to patients to encourage members to join.

Safeguarding: a dedicated safeguarding champion who works closely with the clinical safeguarding leads to ensure all patients, both children and adults, are offered advice and support. Regular contact is maintained with the local safeguarding team, and the register is monitored and reviewed regularly. Feedback is given at each practice/safeguarding meeting.

COVID: a dedicated COVID champion to ensure compliance and safety is in place for staff and patients. Regular updates are circulated, and new guidance is implemented safely and effectively.

Suicide: a dedicated champion who helps clinicians to support patients who have expressed suicidal thoughts or experienced the suicide of someone close to them. Regular contact with patients and awareness of help and support is maintained.

Loneliness/isolation: a dedicated champion to consolidate welfare checks on patients to make sure they are being supported socially. This includes their ability to look after themselves in terms of shopping for essentials, interacting with people on the phone, or having someone drop off medication.

Bereavement: a dedicated champion who engages with families which have lost loved ones, offering support and signposting to other available services.

Young families: a dedicated champion to engage with families and young people, monitoring health requirements such as child immunisations and vaccine recommendations for young adults, such as MMR and MenACWY. This also includes encouraging engagement in sexual health programmes and awareness.