How this PCN improved learning disabilities care

Barnet PCN3 is one of the seven networks shortlisted for PCN of the year. It has transformed how it cares for patients with learning disabilities by creating a dedicated PCN-wide team. Clinical director Dr Nufar Wetterhahn explains more.  

Barnet PCN3 has a significant number of patients with learning disabilities (339) out of a total list size of 72,711. We set out to create a service that was centrally organised for all seven practices to provide personalised and holistic care to our patients with learning disabilities.

We first developed a process for a PCN-led learning disability annual health check (AHC) in March 2022 and then added other features after feedback and reflection. The additions include cancer and vaccination screenings, recording reasonable adjustments, and follow-up structured medication reviews by a designated pharmacist. 

Last year, we developed it further again by collaborating with partners to add a one-stop shop to the service. Patients are seen in a non-clinical setting by various members of a multi-disciplinary team.

This project has improved care for patients with learning disabilities and reduced workload on individual practices. It has also increased collaborative working between primary care and community partners. 

Aims

The project’s ambition was to transform our interactions and support for patients with learning disabilities and enhance screening across all PCN practices. We aimed to enhance our care model by collaborating with community providers and the voluntary sector.

We recognised the complex health inequalities faced by the learning disabilities cohort would require a nuanced and personalised approach. Taking time to understand any barriers so we could better support the patient was important. So, we used ARRS funding to form a dedicated team at PCN level to provide a comprehensive learning disability service for our patients. Our team includes two speciality care coordinators (with training provided to all other care coordinators too), two nursing associates, one senior pharmacist, and one nurse lead for oversight and supervision.

We’ve learned that having one well-trained and supported team is crucial for providing consistent and high-quality care across all practices. As patients feel more comfortable with the PCN learning disability (PCN LD) team, they engage more readily during subsequent encounters.

The team is led and supported by the PCN clinical director, the head of business and transformation (who is also the health inequalities lead).

 Approach

Creating a team involved the recruitment of dedicated care coordinators whom we trained to navigate the challenges associated with the learning disability cohort, such as an understanding of reasonable adjustments, exploring the difficulties patients face when attending practices, and reasons behind missed appointments.

Training was provided by a combination of practice staff (who were previously providing the learning disability AHC) and targeted training by the community learning disability team and the PCN lead nurse who delivered screening training. The care coordinators also have ongoing support from the PCN lead nurse.

The care coordinators actively engage with patients on the phone during the booking of the AHC, focusing on a personalised and supportive approach that includes making a note of reasonable adjustments required in the medical records.

The delivery of the learning disability AHC is conducted by our nurse associate, who then refers all patients who are on medication to a designated senior pharmacist for a structured medication review. 

During patient interactions, we prioritise cancer screening with easy-to-read literature and weight management support. This aligns with a broader PCN commitment to preventative healthcare. Our proactive approach reflects a forward-thinking strategy to improve long-term health outcomes for our patients. 

Collaborative working

After a successful start to the project, we applied for neighbourhood funding through the ICB to extend the AHC offer and launched a one-stop-shop for the AHC in collaboration with community provider Central London Community Healthcare NHS Trust (CLCH) and voluntary organisations Barnet Mencap and Barnet Carers. 

Our neighbourhood partnership project is a one-year pilot, set up at a local community centre which provides a space for patients with learning disabilities to have their AHC in a non-medical environment and engage with multiple services in one space. 

As well as boosting the patient experience of those with learning disabilities, we wanted to improve the support for carers to help with non-clinical aspects of care. We offer this service through Barnet Carers, which is present at the one-stop shop.

In spring 2024, we introduced a ‘check and test’ add-on to the AHC. This includes a comprehensive physical review of any long-term conditions, such as diabetic foot checks, peak flow recordings and urine checks.

This approach allows us to offer a comprehensive follow-up appointment which includes two reviews in one – a structured medication review and long-term conditions review in one consultation – which minimises multiple recalls and appointments for a cohort that’s often challenging to engage. 

Challenges

This patient group often change their minds about attending appointments and screening. They have previously experienced difficulties accessing care and need time to develop trust and confidence in our team. After initially planning for 400 health checks at the community clinic, we had to adjust our expectations down to 300 because we realised that these patients require extra time and support, especially when receiving care in unfamiliar settings.

Collaborating with community and voluntary partners has been rewarding, but we underestimated the amount of administration and time needed to coordinate clinics and follow-ups during the initial planning stages.

Combining and navigating various reporting systems and learning each other’s ways of working has also been quite challenging. It required significant PCN oversight and coordination with all partners to ensure the smooth operation of the one-stop clinic.

Outcomes

Implementation of reasonable adjustments has notably enhanced patient experience – there has been a 93.5% increase in them since starting this project.  

We achieved a completion rate of 92.3% for learning disability AHC 23/24, which is well above the national average of 80%. In 2018/19, which was prior to the PCN, our AHC completion rate was 53%.

As well as a high completion rate, our care model has significantly reduced practices’ required interventions. Last year, we provided 584 specially tailored appointments to the learning disability cohort across the PCN, saving member practices over 300 clinical hours.

Our one-stop shop has also been a success. Many patients prefer the multidisciplinary team approach and the ability to speak to multiple teams in the same location. We have offered 300 appointments over a year in our one-stop clinic, including call and recall work being done at PCN level. Those who prefer a quieter environment or have specific needs can still have reviews at practices. We record patient outcomes and feedback, collating them onto joint spreadsheets.

The PCN is continually evolving its care model by incorporating feedback and using data analytics to inform the decision-making process. By prioritising patient-centred care and remaining open to change, we ensure that our services remain responsive, relevant, and effective.

Profiles of the shortlisted PCNs will feature on Pulse PCN in the run up to the awards night on December 6.