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Our Workstreams

The Enhanced Primary Care Contract includes two main elements:

  • Out of Hospital Services
  • Population Health Management

Out of Hospital Services

Hammersmith and Fulham GP Federation has a contract with Hammersmith and Fulham Clinical Commissioning Group to ensure delivery of a wide range of services that have historically been provided in hospital. The provision of these services by trained clinicians in GP practices ensures greater accessibility and convenience for you.

These services include:

  • ABPM (Ambulatory Blood Pressure Monitoring)
  • Warfarin Monitoring & Advanced Monitoring
  • Wound Care
  • Diabetes
  • Non Diabetic Hyperglycemia
  • ECG (Electrocardiogram)
  • Homeless services
  • Near Patient Monitoring
  • Phlebotomy (taking blood)
  • Ring Pessary
  • Spirometry
  • Mental Health services

All 29 GP practices in Hammersmith and Fulham provide all or some of the above services. Where a practice does not provide a specific service, you will still be able to receive it from a neighbouring practice in Hammersmith and Fulham.

For more information, please click here or speak to your GP practice.

Population Health Management 

Hammersmith and Fulham serves a population of 260,000 registered patients, representing a GP membership of 29 practices, arranged into 3 GP networks. The GP Networks ultimately provide a clinical forum and serve to enable the sharing of best practice, discuss how they can improve the quality of the services and deliver these services at scale.

Hammersmith and Fulham Clinical Commissioning Group has recently contracted with all Hammersmith and Fulham GP practices to work collaboratively with neighbouring surgeries in order to improve the health of their local population.  Hammersmith and Fulham GP Federation has a key role in supporting the GP Networks to come together to achieve better health outcomes for their patients through:

  • Identifying and supporting the needs of General Practices
  • Supporting the delivery of the out-of-hospital services and ensuring that all patients are able to access all services available
  • Specialist clinical support to improve the quality of services
  • Reviewing population health across a range of disease areas and helping GP Networks to create a plan to address health inequalities in their network

The aim of the Shared Services – Document Processing (SSDP) project is to make the processing of documents through the GP surgeries more efficient.

Typically all or most documents (for example from hospitals) are sent to GPs - or other practice clinicians such as Nurses or Pharmacists - to action. This can lead to valuable GP time being spent on documents that can be safely dealt with by other properly-trained staff.

The SSDP team “triages” documents taking appropriate actions, adding relevant codes in the clinical system, and forwarding to clinicians where further action is required.

The SSDP team includes administrators and pharmacy technicians (PTs). The PTs have the skills and knowledge to set up repeat medication when clearly indicated in hospital discharge letters. When changes are made they are flagged for checking by GPs.

The service offers support to a number of practices using a core set of processes tailored where appropriate to individual practices requirements.

All participating practices use SystmOne (S1) as their clinical system.

The SSDP team works under the direction of the relevant GP practice, to a set of agreed procedures and processes.

The Hammersmith & Fulham GP Federation's Clinical Governance team supports practices with quality improvement activities to ensure the quality and safety of the services they deliver. This includes performing clinical audits, monitoring safety and quality indicators, supporting practices to analyse incidents and significant events, sharing learning amongst GP practices, and supporting clinical staff.