The Community Wellbeing Team consists of 3 Community Wellbeing Advisors (Social Prescribers) that offer primarily telephone appointments for help with accessing support. If you don’t feel comfortable speaking to them over the phone, then a face-to-face appointment may be arranged.

What can they help patients to access support with?

– Money Matters (accessing debt support, benefit advice or food vouchers)
– Housing Issues
– Accessing social groups in the local community
– Finding new hobbies and interests
– Linking in with employment/volunteering support
– Linking in with family support services
– Support to access mental wellbeing support
– Referring people to smoking cessation, healthy eating or physical activity support
– Linking patients in with support for sleep management
– Helping carers to access support
– Linking with support for sexual, domestic or childhood abuse
– Signposting patients to access support around drug/alcohol abuse

Appointments with the Diabetes Dietitian usually last around 45 minutes, with follow up review appointments lasting around 30 minutes. Appointments are available via telephone on Thursdays, or face to face available on Mondays at West Lodge Surgery, Tuesdays at Robin Lane Health and Wellbeing Centre and Wednesdays at the William Merritt Centre.

What can our Diabetes Dietitian help with?

Adults aged 18 or over with:

– Pre-Diabetes who do not meet the criteria below
– Type 1 Diabetes who do not engage with the diabetes centre at St James’ Hospital
– Type 2 Diabetes on any medication who do not meet the criteria below e.g. malnourished/frail (Please see Frailty Dietitian for these conditions)

Who is not suitable for this service?

– Patients under 18 years old
– Patients who are frail or malnourished with type 2 diabetes (please refer to our Frailty Dietitian)
– Patients under the Leeds Community Healthcare (LCH) Diabetes Team
– Patients under the Diabetes centre at St James’ University Hospital
– Patients who are overweight/obese requiring weight management advice who do not have Pre-Diabetes or Diabetes
– Severe mental health issues under the care of St Mary’s Hospital
– Diagnosed eating disorder under CONNECT eating disorder service or another specialist eating disorder dietitian

Appointments with the Frailty Dietitian usually last around 45 minutes. Both face to face and telephone appointments are available. F2F appointments are located at West Lodge on Tuesdays or William Merritt Centre on Thursday mornings, with Care Home visits occurring on Wednesdays and home visits on Fridays for housebound patients.

What can our Frailty Dietitian help with?

Our Frailty Dietitian can deal with a broad range of complex medical conditions, offering specialist advice to patients, family and carers. Including:

– Frailty
– COPD
– Poor oral intake
– Disordered eating
– Diet modification
– Heart health
– Pressure ulcer
– Neurological conditions
– Post Operative nutrition
– Weight loss
– Sarcopenia
– Stroke (Only when discharged from LCHCT)

Who can we help?

– Adults 18 years or over with a long term condition or at risk of frailty

Nutrition support should be considered in people who are malnourished as defined by the following:
– A BMI of less than 18.5kg/m2
– Unintentional weight loss greater than 10% within the last 3-6 months
– A BMI of less than 20kg/m2 and unintentional weight loss greater than 5% within the last 3-6 months.

Nutrition support should be considered in people at risk of malnutrition who are defined by any of the following:
– Have eaten little or nothing for more than 5 days and/or are likely to eat little or nothing for the next 5 days or longer
– Have a poor absorptive capacity, and/or have high nutrient losses and/or have increased nutritional needs from causes such as catabolism.

Please note this service is not suitable for people with an eating disorder, uncontrolled diabetes or severe mental health issues under St Mary’s Hospital care.

What are Primary Care Support Workers?

Primary Care Support Workers function similarly to Health Care Assistants found in GP Practices and work either in practice or perform domiciliary appointments for those that are housebound.

What can the Primary Care Support Workers do?

– Blood Tests (Performed at all practices or on Home Visits)
– Blood Pressure (Performed at all practices or on Home Visits)
– ECG (Performed at all practices)
– Vaccinations B12 or Flu (B12 only available to perform at Hillfoot Surgery)
– NHS Health Check (performed at all practices or on Home Visits and takes around 20 minutes)
– SMI Physical Check (performed at all practices or on Home Visits and takes around 20 minutes)
– LD Physical Check (performed at all practices or on Home Visits and takes around 20 minutes)
– Dopplers with No Dressing (at Hillfoot Surgery only and takes around 20 minutes)
– Dopplers with Dressing (at Hillfoot Surgery only and takes around 40 minutes)
– Stocking Measurements (performed at all Practices and takes around 10 minutes)
– Foot Checks/Diabetic Check Part 1(performed at all practices or on Home Visits and takes around 10 minutes)
– Long Term Conditions (performed at all practices or on Home Visits and takes around 20 minutes)
– Paediatric Bloods (performed at all practices)
– Removal of Sutures/Staples (performed at all practices and takes around 20 minutes)
– Spirometry (at Hillfoot Surgery only and takes around 50 minutes.)
– Feno Adult (at Hillfoot Surgery only and takes around 10 minutes)
– Feno Child/Learning Disabilities (at Hillfoot Surgery only and takes around 20 minutes)
– Wound Care & Dressings (performed at all practices, 20 minutes for simple and 40 minutes for complex dressings)

What does the Frailty Team do?

The role of the Frailty Team is to manage older patients living with complex needs. They undertake comprehensive assessment, care planning, ordering, acting upon diagnostic tests, as well as making referrals. Comprehensive clinical assessment includes memory screening, medication review and a discussion about wishes and preferences for future care.

The team can refer to in house PCN teams or onwards to social services, NT/CM, Therapy Team, equipment provision, smoking cessation, Dietitian, SALT and all specialist referrals needed.

Following a comprehensive assessment, patients may receive treatment for acute conditions as well as a review of their medications, aiming to see all patients falling into the severely frail category.

What are the benefits for patients?

The role of the Frailty Team is to support frail people to live independently for as long as possible providing all tools and support needed to achieve it. This will help to reduce avoidable admissions to hospitals. Older people can live with several health conditions and a gradual decline may be missed until a crisis occurs: preventative work can help to avoid a person reaching a crisis.

Patients have an opportunity to discuss their health and social situation with friends or family present to ensure that their wishes are heard and a care plan is made.

What are Physician Associates?

Physician Associates (PAs) are medically trained, generalist healthcare professionals who work alongside doctors and provide holistic medical care. PAs are dependent practitioners working with a dedicated medical supervisor but can work autonomously with appropriate support. They also work under the supervision of the GP consulting with patients. In the first instance, they will be doing minor illness clinics as seen below but can also conduct home visits if needed. They are not able to prescribe.

Who can Physician Associates see?

PA’s appointments may be booked in by the practice based on if you experience any of the below symptoms when calling up your GP Surgery:

Those with the following conditions may been see by a PA:
– Coughs/colds/flu like symptoms
– Sore throat/tonsilitis
– Ear pain/hearing loss/tinnitus
– Rashes
– Back pain/joint pains
– Urinary tract infections
– Diarrhoea/constipation
– Vomiting
– Abdominal pain

Exclusions for who they can see

– Children under 2 years old
– Pregnant people
– Palliative care patients
– Patients with severe mental illness

What is an Occupational Therapist?

Occupational Therapists are registered health care professionals trained in both mental and physical health that understand the impact of social influences on wellbeing. They are experts in assessing the impact of illness and injury on everyday activities.

For Occupational Therapists, the term occupation means any activity that a person engages in that is goal-orientated, personally meaningful, repeatable, and perceived as ‘doing’ by the individual.
Occupation mobilises all facets of a person – their physical being, their psychological functioning, and their social and cultural identity; this has huge transformative potential when harnessed as Occupational Therapy to address specific needs or challenges met in daily living.

Appointments are primarily either telephone or face-to-face.

What can our Occupational Therapists assess?

Any functional difficulties impacting health and/or quality of life. OTs can deliver assessment and intervention for a broad range of conditions including:

– Memory problems
– Frailty
– Fatigue
– Pain Management
– Sleep Disturbance
– Vocational Rehabilitation (Stress/anxiety/advise on reasonable adjustments relating to work)
– Mental Health Assessment

The service aims to provide short-term, brief intervention (i.e. 1-4 sessions depending on need). Please note the list above is not exhaustive.

Appointments with our Weight Management Health and Wellbeing Coach are currently being pulled from a waiting list and due to demand may take longer to process new referrals.

This service is available for adults with a BMI over 25kg/m2 or 23.5kg/m2 for BAME who:

• – Want to make lifestyle changes to lose weight and/or exercise more
  – Are at risk of long-term health conditions such as type 2 diabetes, pre-diabetes, hypertension and high cholesterol.
  – Have been offered and declined/not suitable for community weight management services.

The screening clinics are for patients that are overdue/non responders to cervical or bowel screenings. If you have a patient that is perhaps unsure about screening and would benefit from a chat with someone to give them further information or encouragement, these are the slots for that.

The review slots are for patients that have a cancer diagnosis and are due for the 3month & 12month check up. The cancer reviews are more similar to welfare checks rather than medical interventions and include things such as signposting to support services, checking on the patient/their families and how they are coping, offering financial support etc.

These appointments are all telephone appointments and are available Wednesday – Friday.

At WLPCN, we have a dedicated LD/SMI Care Co-ordinator working with patients that have LD (Learning Disabilities) or SMI (Severe Mental Illness) to ensure that their health checks are completed each year.

LD Health Check

With the LD Health Check, our care co-ordinator sends out an easy read letter and booklet questionnaire to the patient for them/their carer or supporter to fill in. The care co-ordinator will then usually call a week later to book them in for their health check and go through the questionnaire. They will then book the patient for their physical health check and then in with a GP where necessary.

SMI Health Check

The Care Co-ordinator will call patients to book them in for their annual health check. This consists of 2 appointments: the first is the health check usually with a nurse or HCA at the patient’s surgery. The second is a structured medication review with one of the PCN Pharmacists.

On the first call, they will go through some health and wellbeing questions with the patient that are part of the health check. At the end of the process, the patient will receive a call to go through any relevant signposting.

Physiotherapy appointments are available on the below dates:

Monday – Glenlea Surgery
Tuesday – Manor Park Surgery and The Gables Surgery
Wednesday – Hillfoot Surgery and a telephone clinic is available
Thursday – Robin Lane Health and Wellbeing Centre and The Gables Surgery

Injections are available, but an initial assessment would be required to determine if this is the correct treatment need for you.

Clinics ran by the PCN Nurse

Our PCN Nurse covers multiple clinics. These range from asthma reviews or reviewing those with COPD, a smear clinic as well as a travel vaccination clinic. These are run on the following days:

Monday – face to face Asthma Clinic (am) at Manor Park Surgery – Smear Clinic (pm) at Manor Park Surgery

Tuesday – telephone Asthma Clinic (am) – Travel Vaccinations (pm) at Hillfoot Surgery

Travel Vaccinations

Please ensure you book in to this clinic 8 weeks or more prior to travelling and the correct paperwork has been collected from your practice. This is to allow us to purchase the relevant vaccine in good time for your appointment. If you need a travel vaccination and you are travelling within the next 8 weeks, you will need to attend a private travel clinic. Below is a list of private travel vaccination clinics:

STA Travel
88 Vicar Lane, Leeds, LS1 7JH – 0871 702 9827

SF Screening and Vaccination Service
Woodhouse Medical Practice, Cambridge Road, Leeds, LS6 2SF – 0113 295 3510
www.sfvaccinations.co.uk

Superdrug stores

Midway Pharmacies

The West Leeds PCN Pharmacy Team aims to improve outcomes for patients through structured medication reviews and shared decision making, working closely with patients to embed personalised care plans and optimal medication regimes.

The patient populations we focus on include care home patients, frail patients, patients with multiple long-term conditions including cardiovascular patients (such as those with high blood pressure, high cholesterol, atrial fibrillation, heart failure and post-MI patients), diabetes patients, patients with kidney disease, patients with severe mental health and learning difficulties and respiratory patients.

Our Pharmacy Technicians work with patients who have had a hospital stay or multiple medicines changes to support them after discharge, ensuring a seamless transition of care. They carry out safety audits and support our dedicated care home Pharmacist with all aspects of medication reconciliation for care home patients. We have a prescriptions clerk who supports our technicians and pharmacists with safety audits, care home administrative work, arranging rotas and processing clinical documents. We are also a teaching team. We supervise and mentor both trainee pharmacists and trainee pharmacy technicians.

The team follows best practice and works closely with all practices across the PCN to support with any complex medication queries and medication reviews to ensure we are consistently delivering a high standard of care to all our patients. The team also work closely with practice pharmacists ensuring as a team we provide the best possible patient care.

Our Cardiac Nurse is working with patients who need a 6 monthly or annual heart failure review. The appointment will include an assessment of suitability for titration of medication, assessment of symptoms, education around the importance of self-management and early symptom recognition. Our Cardiac Nurse can also do annual chronic kidney disease reviews to ensure that patients are on the right treatment to keep their kidney condition stable.

Appointments with the Cardiac Nurse are a mixture of face-to-face and telephone appointments. Face to face clinics are available at Manor Park Surgery on Mondays, West Lodge Surgery on Tuesdays, Robin Lane Health and Wellbeing Centre on Wednesdays. Telephone appointments occur on Thursdays, with the Nurse doing home visit appointments for housebound patients on Friday’s.

We have some other services, with most available on evenings or Saturday’s. Below are a list of what services are available:

– Smear clinics (face to face at the Gables Surgery on Saturday mornings)
– Pharmacy Appointments e.g. for medication reviews
– Coils and Implants (face to face at the Gables Surgery on Saturday mornings)
– Healthy Minds – mental health service (face to face at the Gables Surgery on Saturday mornings)
– Weekend GP (face to face at the Gables Surgery on Saturday mornings)
– Physiotherapy (face to face at the Gables Surgery on Saturday mornings)