1. Dr. David Lyon Clinical Governance Lead Halton PCT GP Affiliate NPDT

2. The art of Medicine is to amuse the patient whilst nature cures the disease Voltaire

3. TOP BOTTOM

5. NSF Recommendations for Those with Established Disease Risk factors assessed, documented & advised, especially smoking. Medication: aspirin, beta blockers, ACEI Blood Pressure below 140/85 Blood cholesterol lowered to less than 5mmol/l and LDL-C below 3mmol/l or by 30%

7. Getting the Ball Rolling Disease Registers from medication & READ coded entries Additional Nurse Resource Devolved to Practices Protocols for Nurse & for Referral to Secondary Care Computer Templates Audit Team Geared up to Provide Rapid Feedback

11. Advantages of Templates Quicker entry of standard data Consistent use of READ codes Display previous recordings Search for previous interventions Automatic calculations, e.g. BMI, risk score Clinician can be reminded of interventions Easier audit

13. % Population with IHD Runcorn

14. % Co-morbidity

21. Clinical Governance Protected Time for Regular Team Meetings Significant Events Premature Deaths New Cancer Cases Unpleasantness In The Waiting Room Summaries to Clinical Governance Team SEA News

24. What Happened Focus on the facts No blame Its the system What went well What was OK What could have gone better What should we do next time?

25. Acute Chest Pain Protocol Is the patient alert? Is the patients breathing normal? Is the pain severe? Is there heart problems or diabetes? Is it heavy, crushing, pressure or tight? Is there nausea or vomiting? Is the patient sweating or clammy?

26. Acute Chest Pain Protocol 51 cases in 12 months 10 (19%) MI 1 had VF within 5 minutes 7 (14%) crescendo angina 24 (47%) admitted to rule out MI 8 (16%) had blood test etc. & discharged 2 (4%) dysrhythmia Call to needle time less than 60 minutes

28. Cardiac Events Castlefields Health Centre

29. Cardiac Events per Thousand

30. DEATHS Practice records ONS (Office of National Statistics) Public Health 3 Character Postcodes Trend over Time Twelve Month Periods

33. At Risk Other Athersclerotic Disease Diabetes Hypertension Heart Failure Middle-aged men Strong Family History Smoking, Post-menopausal women

34. Essential Ingredients Clear evidence and Clear focus Examples From The Field Time to consider solutions Reality of working at street level Systematic recording of information Rapid feedback Appropriate resources Skilled management