How this PCN…delivers proactive care

Winner of the PCN of the Year category at the General Practice Awards, Central Cheltenham PCN, shares how this network is proactively caring for patients. Clinical director Dr Olesya Atkinson explains

During the last four years, our PCN has transitioned from six individual practices working in complete silos to a mature PCN with collaborative working and innovative practice evidenced on a weekly basis.

Our 57,000 patients benefit from new additional services provided by 33 patient-facing and background staff with a wide range of skill-mix. The workforce recruitment was evidence based, informed by the results of a PCN-wide audit to identify which roles would have the biggest impact on the GPs’ workload and also matched to the population demographic.

Our additional roles reimbursement scheme (ARRS) teams have a clear management structure, regular supervision and peer support which is delivered by a dedicated educational lead and an advanced clinical practitioner lead to support career progression.

We developed a PCN lead nurse role to: support the nurses across all the PCN practices; enable more peer networking; standardise clinical protocols and nurse training; bring specialist care into the community such as diagnostic respiratory service and MDT diabetes care.

Using these ARRS staff, the PCN has been proactive in its delivery of care to patients particularly those who are substance misusers, children and young people, and those who are nearing the end of life. We have also set up a musculoskeletal (MSK) service and a befriending scheme.

Substance misuse

Business intelligence data identified that a practice in our PCN had the highest prevalence of substance misuse in our locality, prompting a call for action. A cohort of patients was identified. Case notes analysis
showed that nine patients were already deceased (all under the age of 50), and 43% were without full Covid-19 vaccination, highlighting health inequalities.

An initial attempt to engage with the remaining cohort from the surgery was unsuccessful. All patients were contacted by the practice with an offer of personalised health support, but nobody took it up. We
realised we needed to think differently and deliver support outside the traditional setting of a GP surgery.

The project aim was reframed with PCN staff going to the patients to find out how to provide a joined-up service to people who do not access health services in the traditional way, and to give us the opportunity for interventions to prevent future decline in health and wellbeing.

The PCN project was run by our lead nurse, who identified where and how best to engage with this cohort in partnership with statutory and voluntary organisations. Working collaboratively, we offered support services anchored around the local charity for vulnerable, disadvantaged and lonely people, Open Door, which provides safe spaces and meals for 70 guests per day.

The following interventions have been delivered:

•A total of 44 people were screened for hepatitis C – three were positive
and are now receiving treatment at Open Door.
•Three people were screened for abdominal aortic aneurysm.
•A total of 36 Covid-19 vaccinations were given and 24 flu vaccinations.
•We did 12 blood pressure checks and referred two results to the GP.
•Art-based mental health interventions were provided through Artlift.
•Social prescribing link workers were connected to the community services.
•We introduced the C card scheme, which allows young people to access free condoms and lube.
•Psychological therapies were offered – both on individual and group basis and through funded iPads. There were weekly on-site clinics with a mental health nurse.
•Open Door staff were trained by the mental health team.
•Links were created with ‘Cheltenham Know your patch’ the local online platform to connect local people, places and activities. •We offered green space on prescription – social prescribing to connect disadvantaged and vulnerable people to nature-based activities.

As the next step, we are gathering further data across Cheltenham to identify hot spots for substance misuse and anti-social behaviour in the local communities. We have already identified a community hub
that is ideally placed to provide outreach support using the successful principles of Open Door.

Young people

We are also working beyond our PCN boundary with schools and have established an innovative population health management (PHM) project to identify children and young people (CYP) at risk of future health and wellbeing problems and offering bespoke, proactive intervention.

Our CYP PHM project has been captured as best practice by the NHSE PHM team and featured in the Gloucestershire integrated care board (ICB) news. More than 50 children are now receiving tailored care to help prevent long-term mental health problems.

They are being proactively contacted by our CYP social prescribing link worker and offered a six-week face-to-face course on mental health resilience, including personalised support with issues such as anxiety or educational difficulties. Their progress is captured through improvement in strengths and difficulties scores (SDQ).

The course also includes topics such as the importance of going outside, appropriate relationships, having fun, healthy eating, managing emotions, friends and family. For parents this can help with parenting skills, routines and boundaries.

Annie Anderton is a CYP prescriber at the PCN who works for Caring for Communities and People, a voluntary sector organisation working with the PCN to deliver the scheme. She says: ‘The children being offered this programme are not known to other services so we’re supporting a group who otherwise might not have received any help. This is advanced proactive care and we’re excited to be able to identify
and help so many young people and positively influence their lives.’

Parents of children who might benefit were written to by Annie’s team via the six GP surgeries involved and asked if they would like to meet with the social prescribing team, under no obligation.

Annie says: ‘So far, no one has turned us away. In fact, parents are delighted to receive extra help. This is about building resilience and helping parents and their children to get support if they feel they want it.’ As the next step, we are lobbying our ICB to refocus the priority on prevention and early intervention.

We are also piloting an exciting role, the Bluebell worker, whose aim is to provide holistic, non medicalised support to young people who are on a waiting list for child and adolescent mental health services (CAMHS). We have built on our relationships with local schools and have placed the Bluebell worker in a secondary school in the most deprived part of Cheltenham. We are hoping that with this early intervention, some young people will be able to come off the CAMHS waiting lists, or at least avoid a crisis.

Proactive end-of-life care

Our PCN has implemented the virtual whiteboard, an innovative digital tool that proactively identifies patients who nearing the end of their life. Patients are contacted by a care co-ordinator to uncover any outstanding health and care needs, in consultation with the family and carers. Advanced care planning conversations are captured in a personalised care folder. The pilot surgery contacted about 350 patients, and evaluation has shown an increase in the number of people dying in their preferred place of death, completed ReSPECT forms, reduced A&E attendances and unplanned admissions.

MSK service
The PCN has set up a first contact practitioner (FCP) MSK service, which has been showcased by the Chartered Society of Physiotherapy. Patient surveys show a high level of satisfaction: 90% rating the service as excellent or outstanding and 100% being happy to use it again. The service has redirected a significant amount of work from GPs.

Befriending scheme
We have strong links with our local voluntary services partners, Caring for People and Communities, and have developed a befriending scheme using community volunteers who receive robust training to provide one-to-one support for vulnerable and socially isolated adults. Referrals to the befriending service are facilitated by the PCN social prescribers who also recruit volunteers. So far the scheme has supported 16 people.

The General Practice Awards are run by Cogora, the publisher of Pulse PCN. These awards highlight innovation in primary care across the UK. This article is part of a series on the shortlisted PCNs.