Hereford Medical Group Primary Care Network

 

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Primary Care Networks

Since the NHS was created in 1948, the population has grown and people are living longer. Many people are living with long term conditions such as diabetes and heart disease or suffer with mental health issues and may need to access their local health services more often.

To meet these needs, GP practices are working together with community, mental health, social care, pharmacy, hospital and voluntary services in their local areas in groups of practices known as primary care networks (PCNs).

PCNs build on existing primary care services and enable greater provision of proactive, personalised, coordinated and more integrated health and social care for people close to home. Clinicians describe this as a change from reactively providing appointments to proactively caring for the people and communities they serve.

PCNs build on existing primary care services and enable greater provision of proactive, personalised, coordinated and more integrated health and social care for people close to home. Clinicians describe this as a change from reactively providing appointments to proactively caring for the people and communities they serve.

Due to HMG’s size we were able to form a Primary Care Network.

Each of the 1,250 PCNs across England are based on GP registered patient lists, typically serving natural communities of between 30,000 to 50,000 people (with some flexibility). They are small enough to provide the personal care valued by both people and GPs, but large enough to have impact and economies of scale through better collaboration between GP practices and others in the local health and social care system.

PCNs are led by clinical directors who may be a GP, general practice nurse, clinical pharmacist or other clinical profession working in general practice.

 

Major achievements during 2021/22

HMG PCN continued to vaccinate patients in line with the national Covid-19 immunisation advice running regular clinics at Quay House Medical Centre and providing vaccinations to housebound patients and those living in nursing and care homes. This was undertaken working in partnership with Herefordshire PCNs to respond to the challenges of delivering this unprecedented vaccination programme.

The PCN has continued to be successful in recruitment to multiple Additional Roles (ARRS), and currently has 27 staff employed under this scheme with a further 3 to join the team by the end of March 2023.

The roles include:

  • Care coordinators
  • Pharmacists
  • Pharmacy technicians
  • Social prescribers
  • Advanced practitioner to lead our enhancing health in care homes work
  • Physicians associates
  • Trainee nurse associates
  • First contact physiotherapists

HMG PCN has also been developing a close working relationship with colleagues in WBC PCN with the aim of making it more efficient for external partners across the city to link with primary care

HMG has developed a number of monthly Multi-disciplinary team meetings to improve patient care and aide the development of staff, including:

  • Palliative care meeting
  • Diabetes review MDT
  • Mental health MDT
  • Complex patient MDT
  • Housebound MDT
  • Respiratory MDT
  • Care home MDT
 

Key focus areas for 2022/23

  • Proactive identification of further vulnerable groups of patients and working with partners to care for them with a personalised care approach. Specifically identifying areas where there are health inequalities and developing projects to tackle these.

  • Working with our care and nursing homes to support staff and residents under the Enhancing Health in Care Homes (EHCH) service.

  • HMG's Clinical Lead for EHCH, and PCN Manager are working closely with care homes; looking at ways to improve communication and support. HMG are keen to listen to and address any concerns care homes may have. The team are also highlighting the benefits of the practice's MDT (multi-disciplinary team) meetings in order to encourage care home attendance. Finally, HMG has been putting homes in touch with other care providers who may be able to provide additional support. 

  • Musculoskeletal (MSK) group consultations – working with first contact practitioners to develop group consultations for patients with a range of MSK problems. 

  • Mental health support: HMG PCN is looking to develop a service to support patients with mild to moderate mental health problems to develop coping strategies and improve their resilience. 

  • The PCN is planning on developing a hub at one of the HMG sites where patients attend for their long-term conditions review. This will be run in partnership with both internal and external partners and enable patients with multiple complex conditions to be seen for all their conditions at one appointment. 

  • Development of a wellbeing team to support patients including social prescribers, health & wellbeing coaches and care coordinators. 

  • Working in partnership with Taurus Healthcare to increase the availability of appointments out of hours in line with patient feedback.

  • Restoring services following the pandemic and vaccination programme delivery. 

 

Key roles within the PCN

  • Dr Erica Sibley & ANP Kerry Mills - Joint PCN Clinical Directors
  • Lucy Jones PCN - Development Manager 
  • Dr Cath Laird  - Non-Executive Director

 

Physiotherapy and First Contact Practioners (FCP) in General Practice. This video feature Claire Strickland, a Physiotherapist who works with HMG in a FCP role

 

Sources