GP Telephone Triage – it makes sense.

Having a conversation with a GP before you consult with them makes a lot of sense, empirically.

I am sure we can all imagine the benefits.

Maybe the issue we have can be sorted out on the phone and not need us to make an apppointment, take time out of work, travel, wait, and in many countries pay for a consultation.

Maybe the issue we have will need some investigations, which could be organised before the face to face consultation so that the GP can help us more effectively when we do meet face to face.

Maybe we can be directed to see a nurse, pharmacist or counsellor who is better suited to deal with our problem.

Maybe the GP will be happier when we do see them because they are prepared for the consultation, and not be feeling that their hard earned skills are being used for low acuity problems.

I have to declare a bias towards the idea of GP led telephone triage, based on the fact that as a working GP I have personal experience of the overwhelming demand patients can create in our traditional model practice that was designed for a time when we had fewer people to care for, who had less complex multimorbidities, lower expectations of the capacity and capability of health services, and higher levels of self and family care.

The “doctor-in-a-box” model that developed in the 1900s has to change to meet the needs of the 21st century patient, and has opportunities to do so in a tech-enabled world that Anuerin Bevan would never have dreamed about.

I value academic study of our profession, I believe that making informed choices about how we progress our services relies on unbiased evaluation of what works well and what doesn’t.

The word unbiased is an essential part of that statement and it’s really frustrating when academic studies of “telephone triage” by GPs present their findings with apparent focus on the negative aspects of the service, and when results do detail positive outcomes, authors and commentators emphasise the negative aspects in discussions and abstracts.

NZ commentators reading : http://www.bmj.com/content/358/bmj.j4345, and http://www.bmj.com/content/358/bmj.j4197 put focus on an INCREASE in the number of consultations found in “telephone first” services, despite the fact that the “change was made up of a substantial reduction in face to face consultations, which reduced from a mean of 13.0 (SD 4.5) to 9.3 (SD 5.5), and an increase in telephone consultations from a mean of 3.0 (SD 4.5) to 12.2 (SD 7.5) telephone consultations/day/1000 patients.”

These systems provide many more opportunities for patients to access care.

NZ commentators focus on an overall increase of 2% in ED attendences but ignore the fact that “Heterogeneity identified with a random effect shows that these figures mask considerable differences between individual practices, some of which had large increases in emergency department attendances, with others showing large decreases.”

They focus on the negative aspects of patient experience in that “just under a quarter reported that it was more difficult to communicate with the GP on the phone, the main reasons being given that it was difficult to explain the problem or that the doctor could not see the problem” and ignore the fact that “nearly two thirds found it made no difference, and 11.7% found it easier to communicate on the phone.”

They ignore the fact that the authors found an “improvement in patients’ rating of time to be seen or spoken to (increase of 20 points on a 0-100 point scale) compared with national trends” and that this was “large and immediate”.

They focus on the “estimated ..overall increase of 8% in the mean time spent consulting by GPs” and ignore the fact that “the average workload figures mask wide variation between practices, with some practices experiencing a substantial reduction in workload and others a large increase” – and that the estimate came with “large uncertainty” (95% confidence interval −1% to 17%; P<0.09)

They don’t mention the fact that there was a “small increase in continuity of care index after the introduction of the new system.”

I wouldn’t be surprised if NZ commentators looked at Catherine Bell’s article in the BMJ “Does Peppa Pig encourage inappropriate use of primary care resources?” BMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j5397 (Published 11 December 2017) and argued that it too demonstrates that telephone triage clearly is a waste of resources.

NZ commentators ignore the fact that our system is very different from that in the UK and the fact of a patient co-payment makes comparisons between the outcomes of trials like this difficult to translate to the NZ context.

The UK system does not filter patients who have to speak to the a doctor on the telephone, every patient HAS to have a phone call with a GP before they can be offered an appointment. This process is not the same as NZ telephone triage where patients are able to make enquiries and be directed to admin or nursing services, they can make delayed consultations if they wish and telephone triage by GPs means they are calling back patients who are seeking same day consultations (or requesting a telephone consultation.)

I could go on and on…but in summary – let’s study the impacts in NZ and not rely on overseas based studies to draw conclusions about our health system, and when the outcomes of a study don’t make empirical sense, let’s consider it a warning to look really carefully at the methodology and results.

Jo Scott-Jones

Burnout

Burnout: “A syndrome of emotional exhaustion, depersonalisation, and sense of low personal accomplishment that leads to decreased effectiveness at work.” ( Maslach 1996)

Surveys of prevalence of burnout internationally suggest that over 50% of primary care physicians admit to one or more symptoms of burnout  and it’s getting worse with time[1]. This is reflected in our collective view of our profession in the RNZCGP annual workforce survey 2015 when less than 20% of respondents were “extremely likely” to recommend GP as a career [2] .

There may be a multitude of reasons for this lack of enthusiasm for our specialty, God knows we don’t do it for the money, but perhaps it also reflects exhaustion and a sense of low accomplishment many of us feel at the end of the day? You tell me – I’m too tired to think about it too much.

Symptoms of burnout include:

Signs of physical and emotional exhaustion – chronic fatigue, insomnia, weakness, poor appetite, depression, anxiety.

Signs of emotional detachment – anger, isolation, pessimism, lack of enjoyment in work.

Signs of reduced effectiveness – complaints from patients and colleagues, poor performance, irritability, apathy. [3]

My own first experience of burnout came as a junior doctor, the only on-site doctor for a community of 30,000 in a 50 bed hospital unit. I was working only the 12 hour night shifts so I could play with my young children during the day, and consequently was sleeping only for a few hours in the middle of the day for months on end.

I can easily put myself back into the emotional space I felt when a poor patient with chest pain arrived at 2 am one morning towards the end of this time.

My only feeling was of resentment that this man was going to be taking up my time which could have been spent having a few minutes sleep. I did the necessary, but had no compassion or ability to empathise left in me.

The only option I could see at the time was to change my job which I did shortly afterwards, out of the frying pan into the fire as it turned out, but that’s another story.

One definition of “stress” is the emotional result of having a gap between how you want or expect the world to be and the reality of lived experience. This means that if we want our patients to be good communicators, who get better as a result of our interventions, and who are cared for in a system that is efficient and responsive we are going to be subject to stress, because patients find it hard to communicate, and the health system is not efficient or responsive.

Add to this reduced resilience through poor sleep, long work hours, the pressures of bureaucracy , a lack of general self-care and you have a recipe for disaster.

So what can you do about burnout?

Prevention is better than cure – stay well, exercise regularly, eat healthy foods, don’t abuse alcohol or other drugs, get plenty of sleep, maintain interests out of medicine, read fiction, be creative, have strong interpersonal relationships and take regular holidays – it ain’t rocket science is it?

If you recognise the symptoms – talk to your own GP – you should have one and get one if you don’t.

Remember “The physician who treats himself has a fool for a patient” (William Osler). Take the advice your GP gives you, even if it involves medication or having a long break from work.

Listen to “The Doctor Paradox” podcast and learn from others how they have coped with burnout [4] – often it involves making a significant change in the way you approach work – I know – this is NOT easy which is why preventing burnout in the first place is a better approach.

Above all else “First you save yourself” – there is no point handing out the oxygen masks to everyone around you whilst you become slowly unconscious. As a profession we have twice the risk of death by suicide compared to the general population and female doctors a four-fold increase in suicide risk[5] – so be careful out there, listen to your body, be mindful of your mood.

Consider whether or not the increasing number of complaints you are receiving is a result of your lack of engagement and not a reflection of the ignorant low life you are obliged to serve – if you think this way it is a symptom of “de-personalisation” and a sign you have a problem, not them.

If you have a lot of  “heart-sink patients” (those whose name in the appointment book makes your heart sink because you feel defeated, overwhelmed and exasperated by their constant demands and unsolvable problems [6])  consider re-framing the problem as being a sign that it’s time for taking a holiday, reading a good book and learning how to play the clarinet.

Dr Jo Scott-Jones

 

 

 

 

 

 

[1] http://www.medscape.com/viewarticle/838437

[2] http://www.rnzcgp.org.nz/RNZCGP/Publications/The_GP_workforce/RNZCGP/Publications/GP_workforce.aspx?hkey=a7341975-3f92-4d84-98ec-8c72f7c8e151

[3] https://www.psychologytoday.com/blog/high-octane-women/201311/the-tell-tale-signs-burnout-do-you-have-them

[4] http://thedoctorparadox.com/

[5] https://www.mcnz.org.nz/assets/News-and-Publications/Newsletter/DEC08.pdf

[6] http://www.bmj.com/content/297/6647/528

Changes in Infectious Disease Legislation NZ

 

Notifiable Diseases and Changes to the legislation since January 2017.

The MOH want GPs in New Zealand to be aware of the availability of updated guidance document on the management of infectious diseases under the Health Act.

It can be accessed from that website at:

http://www.health.govt.nz/system/files/documents/publications/guidance-infectious-disease-management-under-health-act-1956-feb17.pdf.

They recommend that all of your staff who work with infectious diseases and the people who have them are aware of the guidance which is aimed at public health officials and its all interesting but the areas on notification and contact tracing are definitely worth a look for General Practices.

The most important thing for GPs  to be aware of what is happening locally – hopefully you get this information through your supportive and helpful PHO but if there is an outbreak of something your local public health team may ask for more information from your practice.

One question to ask yourself would be :

“Could this practice report easily on who the patients were who had flu like symptoms or gastroenteritis in the past 2 weeks?”

If not – it may be time to think about how you are classifying your records.

Since January 2017 New Zealand legislation allows for FORMAL contract tracing to be implemented for any disease at the discretion of the medical officers of health in a region.

This is most likely to occur when the consequences of a notifiable infection are comparatively severe – such as meningococcal disease, tuberculosis and HIV and when people have had contact with a condition when they have  a higher risk of complications, such as young children, pregnant women, and those with decreased immunity or comorbidities.

However there may be circumstances in which formal contact tracing is appropriate for ‘other infectious diseases’ that are not notifiable (eg, a serious chlamydia outbreak).

The list of notifiable diseases is under constant review and the latest update is available from the MOH website :

http://www.health.govt.nz/our-work/diseases-and-conditions/notifiable-diseases

There are no new suprises here but it’s worth reminding yourself that for example gastroenteritis is notifiable where there is a suspected common source or from a person in a high risk category (for example, a food handler, an early childhood service worker) or single cases of chemical, bacterial, or toxic food poisoning such as botulism, toxic shellfish poisoning (any type) and disease caused by verotoxin or Shiga toxin- producing Escherichia coli.

Be careful out there.

Jo Scott-Jones

Treating Diabetes -GLP-1 agonists

A recent “Tools for Practice” from the fantastic people at the Alberta College of Family Physicians  asks the clinical question “Do glucagon like peptide 1 analogues ( GLP-1 ) improve patient orientated outcomes in type 2 diabetes?”

Diabetes is a key issue for primary care in New Zealand as it is all over the world and anything we can do to reduce the complications is causes has to be looked at seriously.

GPL-1 were apparently extracted from the saliva of Gila Monsters – lizards that eat once a month and need to rapidly increase their insulin production after eating. Administration in humans does the same thing – increasing endogenous insulin and suppressing glucagon. They also are reported to suppress appetite and are associated with a loss of weight of 1- 1.5 kg.

They cause nausea, vomiting and GI side effects and may be associated with pancreatitis.

The Tools for Practice article (albeit for other medications) show numbers needed to treat of 44-53 to show a minimal reduction in CVS risk of 1.3 – 1.6% – and a Number needed to harm of 16-33 for GI irritation, 112 for hypoglycaemia, 83 for retinopathy and gallbladder disease.

The article reviews the data on 2 GPL-1 that are not available here in this country, the only one that is available – Exanatide – is not subsidised – and a review in 2013 from the Best Practice Advisory Centre  and the Medsafe data sheet does not identify any significant reduction in cardiovascular disease outcomes but does find it reduces HBA1c% by around 10 mmol/l – and that it may be a useful 3rd line medication to consider adding to Metformin and a Sulphonyurea.

As the Canadians conclude “clinicians should prioritize pateint -orientated outcomes (like CVD) rather than sugars and microalbuminuria, and meta-analysis of small short trials can be misleading compared to large RCTs.”

I also think I would struggle to find a patient prepared to inject themselves twice a day and to pay for the privilege in my practice.

Conclusion – lots of limitations but something to be aware of.

Dr Jo Scott-Jones

 

 

 

What a wheeze.

The topic of “wheeze” can get very complicated with different approaches needed for adults and children, and different conditions overlapping and changing as a person’s life progresses.

This article links to several resources available and hopefully helps GPs manage the muddle.

Asthma is an illness that is frequently coded in encounters by GPs – and guidelines are pretty straightforward – but this is an area where practices may need to decide on a consistent approach to care.

Under the guidance of the MOH and the new “system level milestones” plan the combined DHBs of Midlands have challenged GPs in the region to reduce admissions for children aged 0-4 years and they have put a particular focus on respiratory disease.

One of our problems looking at the topic is the difference between “wheeze” – the polyphonic high pitched expiratory noise made by restricted airways,  “asthma” the hyperresonsiveness of airways characterised by constriction of smooth muscle, and inflammation and COPD the decrease in airway patency that develops over time and linked to permanent reduction in lung function.

It’s important to remember, the majority of children who wheeze in the first few years of life will “grow out” of the condition.

And interesting to note that around 40% of people with COPD also have asthma.

Prevalence: Let’s look at asthma….  

The latest NZ Health Survey tells us that 11% of NZ’ers and 15% of Maori aged 15 yrs or over are using asthma medications.

asthma-update

Issues: 

 

The Health Quality and Safety Commission tell us that in adults:

  • 82 percent people admitted with asthma did not receive a paid for influenza vaccine in the year after admission. People with asthma should have an annual flu vaccine.
  • Over a third of people admitted with asthma were not regularly given asthma controller inhalers (brown, inhaled corticosteroid) in the year after their admission.
  • In the community,  30 percent of asthmatics regularly dispensed relievers were not regularly dispensed a controller.
  • Admissions for Pacific people and Māori are proportionally higher at all ages than those identifying as European or Other.

They also note young children are much more likely to be admitted to hospital for “asthma” than older children (10 – 14 years) and adults.

HSQC illustrate significant variation from one DHB to another – for example across 4 Midlands DHBs the rate of admissions of children aged 0-4 with asthma or wheeze is shown below:

 

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Why do some DHBs have a lower or higher rate than the national mean ? Does this reflect differences in population or are there other factors?

What can be done to reduce admission to hospital / ED attendance for children with wheeze?

 

DHB variation: 

These DHBs do have some differences in their population make up – but does this explain anything? Is there something special about Lakes that mean the rates of admission is higher? Is it a significant difference?

Is it an environmental issue ? Does it relate to access to services or a different burden of illness?

We don’t know if this something in our control as GPs but it is interesting to note and worth thinking about.

Why do people take their children to ED with wheeze? 

 

Studies suggest that in total only around 11% of use of ED is “inappropriate” .

Preventing patients self-referring with low urgency problems that are unlikely to require admission and are more suitable for other services, such as primary care, telephone advice helplines or pharmacy is a health promotion activity best targeted at parents of young children and at older youths/young adults.

The issues are greatest during weekends and bank holidays and service provision focusing on access to primary care and having urgent care services in the most deprived communities would have the most benefit as would the improvement of parental confidence. 

Parents of children with acute breathing difficulties need those children assessed – and if we are going to have an impact we are either going to need to provide alternative care in the community away from ED that patients will access, or we need to reduce the number of children with respiratory problems.

Preventing the development of asthma itself is in the too hard basket  and until we really understand the causes issues like the “hygiene hypothesis” and prenatal allergen exposure will remain in a dusty corner of the kete.

Exclusive breast feeding in the first few months after birth is associated with a reduction in incidence of asthma, and we do know there is an increase in wheezing illness in children on whole cow’s milk and soy based milk products.

Exposure to tobacco smoke pre and post-natally is associated  with increased wheezing illness in childhood so our efforts to reduce smoking are important.

The key for GPs is going to be in the effective use of treatment for wheeze in children.

As a foundation we all need to develop and maintain good communication with families so that we can provide good quality education and improve concurrence with evidence based advice.

We need to see parental education as a key part of our role as GPs – teaching people what to do when they are worried and showing them what they really need to worry about, and what they don’t need to worry about.

We then need to be there for our patients –  if we cannot provide a 24 hr a day service ourselves we need to show our patients how to access helplines and after hours services that are appropriate to their needs.

The next building block is to be actively engaged in whatever prevention actions that we know will help.

We can help identify and reduce exposure to risk factors – allergens and pollutants both indoor and outdoor, identifying the rare child with food allergy, avoiding using aspirin and NSAIDS, and help weight control.

We can provide effective treatment of rhinitis, sinusitis, and nasal polyps  – this all helps reduce “wheeze” episodes in children.

We forget how important immunisation is sometimes – because we have acheived such a high uptake in our communities – but recent upsurges in pertussis remind us of how important it is that we keep working on this.

Finally we need to provide the best treatment possible.

For younger children the Best Practice Advisory Center tell us that not all that wheezes is asthma in children and their pragmatic approach to symptom management and prevention is great advice.

For older children we need to assess, treat and monitor asthma carefully.

We need to give patients an easy way to assess their own asthma control – using simple questionnaires (even though it is Pharma supported the Asthma Control Test is a good one) or for those capable of using them  PEFR guidelines .

We need to take an evidence based and comprehensive approach to managing asthma – stepping up if symptoms are worsening, reviewing and intervening effectively after an exacerbation, and stepping down if appropriate.

Where do you find the evidence to help you decide what to do ?  

Health Navigator is a great NZ resource to review with great information for patients and professionals – they have a great series of videos talking about how to use inhaler’s properly and what can trigger asthma for patients to view.

Internationally the National Institute for Health and Care  Excellence ( NICE )  gives a detailed and up to date evidence and management guidance around a range of conditions.

Have a look at their pathway on bronchiolitis in children – those of you familiar with “maps” will recognise the algorithm based decision support tool, the layout and windows here are very user friendly.

Any review of guidelines is worth tempering with a health dose of skepticism from the Therapeutics Education Collaboration  if you don’t link to their podcasts and look at the website regularly already make it an early “go to” when you are looking for an update on clinical issues.

The “search” facility doesn’t pull up a lot on childhood wheeze but there’s a bit on asthma and they do link to this interesting COPD tool that shows you your “lung age.”

They also link to Tools for Practice which is another great #FOAM4GP resource that shares the Evidence Based Medicine expertise of the Alberta College of Family Practice internationally.

Combining a scan of all these sites should give you good answers to clinical questions with the latest and best evidence available for example –

In asthmatics, LABA should not be used without inhaled steroids. LABAs increase serious adverse events when used alone, but not when combined with an inhaled steroid (at least in patients >12 years-old). The evidence for benefit of adding in a LABA is very small which is why they are best added in to patients who have significant symptoms despite other therapy.

LABA monotherapy does not increase adverse events in COPD patients  and statistically significantly reduces the risk of COPD exacerbations requiring hospitalization (NNT=56)

 

Unanswered questions :

What would be the impact of using a regular ICS on admission to hospital / ED attendance for someone with poorly controlled asthma? 

Studies suggest this might lead to a 55% reduction in severe exacerbations of asthma.

What would be the impact of flu vaccination on admission to hospital / ED attendence for people with asthma or COPD? 

There is doubt about whether or not flu vaccine helps to reduce asthma exacerbations, but the benefits of flu vaccine across a wide range of parameters including reducing admissions with flu related complications is strong.

 

 

One of the best sources of medical information on line – IMHO.

Best Science in Medicine. 

“BS – Medicine without the BS” – has got to be top of my list as a “go to” podcast for medical information – it is one of the top (typically in the top 3) medical podcasts in Canada and one of the top 20 in most other countries.

It is also supported by a fantastic website and linked to a number of other useful decision making tools. 

FOR A LIST OF ALL THE PODCASTS CLICK HERE

The podcasts are presented by James McCormack and Michael Allan who have presented several times here in New Zealand over recent years invited by the Royal New Zealand College of General Practice.

They promote healthy skepticism and critical thinking and most of the podcasts are presented in a case-based approach. I really enjoy their sense of humour which they build into the whole process to make the learning more interesting. Occasionally they have great guests like Bob Rangno, Adil Virani, Mike Kolber, Tina Korownyk and our own Bruce Arroll help them out.

The overriding messages are:

  1. Be familiar with the evidence (not critical appraisal) for the conditions you treat
  2. Start with low doses unless the condition is life-threatening
  3. Engage patients in shared-informed decision-making by discussing with them their risk without treatment, their risk with treatment, and any potential adverse effects including cost

Click HERE to read some reviews.

Click HERE to subscribe to the podcast via iTunes – you will need to have iTunes loaded on your computer to do this.

If you don’t know how to subscribe to a podcast in iTunes click HERE

Dr Jo Scott-Jones Medical Director Pinnacle.

Taranaki Shout Out ! A Pinnacle Way Adventure Coast to Coast

pinnacle-values

Taranaki GPs in the latest RNZCGP workforce survey were the LEAST likely to recommend General Practice as a career with  net promoter score of -20.

Trekking around Pinnacle MHN practices in the region with business development mangager and network leader Pauline Cruikshank and new GP Liaison and Auckland University Academic C0-ordinator Nadja Gottfert over the last few days it was really hard to match this fact with the enthusiasm and innovation that the GPs displayed.

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At Inglewood Medical Centre  we met Marie Fonseka, Cees Dekker and Steve Finnigan ( second from the left) – the FIRST GP to put his hand up for moving to the new PMS system INDICI which will create opportunities for true patient centred electronic medical records and an ability to integrate care across the whole of the health and social sector.

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At Eltham Health Centre we met Anton Westraad – a solo GP who has championed insulin initiation in rural practices – preventing patients from having to travel an hour to Base hospital to meet with a specialist nurse. Anton’s work has been supported by Pinnacle’s Primary Options funding to keep patients close to home when they have issues like cellulitis, DVT , pneumonia, or needing rehydration after gastroenteritis.

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Gerard Radich and his wife Margot run a solo general practice in Stratford – his dedication to his patients is phenomenal – everyone is informed of every test result, he answers the phones at morning tea time so his staff can have a break – an early demonstration of the benefits of the Health Care Home GP phone triage he finds he can deal with most patients who call during this time without needing a face to face consultation.

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At Patea and District Community Medical trust we saw fantastic leadership in practice manager Christine Steiner who steers a practice in a very high needs community on the edge of the region in a small coastal town two hours away from Base hospital. The regular doctor Maria Beltran De Guervara was away on holiday when we visited but they provide PRIME services and the nurses truly work at the peak of their scope. img_2213

Karen Caskey ( Practice manager) Duncan Burns, Bill Carteledge, and Brian Wood at Avon Medical Centre are implementing the Health Care Home model of care, enthusiastic teachers with 2 RNZCGP registrars booked to learn alongside them in 2017.

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GP educator and ex-GP liaison Dr Viv Law of the Family Health Centre in New Plymouth runs the Taranaki Medical Foundation which Pinnacle supports to provide GPs with regular high quality education events in the region.

And we saw LOTS of Christmas Trees !!

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( Our Favourite !!)  Thanks to Ngati Ruanui Health Care.

So why the low “net promoter”score?

In a meeting with Taranaki CEO Rosemary Clements a group of GPs identified the pressures (and pleasures) of being a solo GP – maybe the need to be “bum up nose down”all the time seeing patients makes them less likely to recommend GP as a career.

The financial pressures on General Practice are worsening year on year – small rural practices really feel the pinch especially if they are Very Low Cost Access and the paperwork involved in managing a practice and compliance costs of meeting regulations and accreditation continue to escalate.

The solution may be to increase the number of training positions in the region for undergraduate and post-graduate doctors and nurses.

Enabling more to be done more simply in primary care through near patient testing and better management of patients as they approach end of life through advanced care planning.

The GP’s in the region discussed the need to change the business model and to look for other sources of funding outside of vote health.

They focused on the need to maintain the current aging work force to be happy and competent for as long as possible so that they as clinicians stay in position whilst new providers are in the pipeline. They also said they wanted a whole system approach to managing patients and look forward to better integration of care across primary and secondary sectors as promised by the Health Action Plan.

Pinnacle’s Mission is to get the best health outcomes for people and their communities and do this by supporting general practice to deliver high quality care.

We are collaborative, adaptive, aware, reliable, innovative, inquisitive, courageous and keen to help !

Dr Jo Scott-Jones ( Medical Director) and Nadja Gottfert (GP Liaison and GP Academic)