How this PCN used collaboration to improve care

South Sefton PCN won PCN of the year at the GP Awards 2024. It was one of the seven networks shortlisted after it undertook collaboration in several aspects of care delivery to improve outcomes. Rachel Stead, strategic PCN manager, and clinical director Dr Craig Gillespie explain more.

South Sefton PCN’s (SSPCN) vision is to enable patients to live longer, healthier lives by being at the heart of our ICS. However, we are operating in a complex and challenged system. The PCN, which comprises 19 practices, covers an economically diverse population of just over 160,000 patients in both the most and least deprived communities in the country. This significant variation means there are stark health inequalities resulting in some of the lowest healthy life expectancies in the country.

By focusing on collaboration and partnership working, we have delivered the three priorities in our strategic plan: to provide joined-up services, expand the primary care workforce, and work at scale to the benefit of patients.

Aims

We wanted to prioritise patient-centred, co-ordinated care, including health promotion, and deliver innovative personalised services to reduce health inequalities.

To achieve this, we set out to forge strong partnerships that would enable us to create new services to help us deliver our vision. We wanted collaboration and partnership working between primary care, community health services, the voluntary, community, faith and social enterprise (VCFSE) sector, local authority and other stakeholders.

The first step was to recruit a senior manager to develop the PCN strategy and build the infrastructure. The PCN strategy was written to reflect local priorities – we focused on what mattered to GPs, general practice staff and our patients. It is ambitious but achievable – and it is written in a simple way. We did this so that it can be understood by everyone in the local system and ensures that PCN members can commit to its delivery. 

What we did

We created a structure based on a neighbourhood model, aligned to the integrated care/neighbourhood team. We split our ARRS workforce into teams:

• Enhanced health in care homes and at home – a frailty service supporting older people to remain well at home

• Primary care mental health

• South Sefton Access Service (SSAS), our acute and minor illness on-the-day service

• Medicines management

• PCN support

Our teams’ strength and success are enabled by our neighbourhood hub and spoke model, embedded within general practice and accessible to patients. The services treat patients more appropriately and quickly, often in their own homes, to reduce the need for secondary care. 

For example, our medicines management worked with a local men’s mental health charity to offer medication reviews at the charity base to men with wide-ranging mental health needs who typically avoided contact with GPs. And our enhanced health in care homes and at home service (EHAH) enables patients to avoid readmission to hospital. EHAH was set up after data in two neighbourhoods showed an opportunity to reduce hospital readmissions amongst frail patients. Collaboration with our integrated care team and Sefton CVS resulted in the formulation of clear pathways that allow coordinators to refer to community services directly.

Integration, collaboration and partnership working have been crucial. An example of this is our PCN mental health team introducing our Adverse Childhood Experiences (ACEs) recovery programme, a group initiative in partnership with Sefton Council. This is delivered from a variety of settings and is accessed by self-referral or via community professionals, such as a vicar.

Due to its success, we are piloting the programme in a neighbouring PCN. We are a founding member of the Sefton Positive and Adverse Childhood Experiences (PACEs) network to develop this agenda, promote consistency and support others to establish similar offers. This partnership is working with the Merseyside Violence Reduction Partnership and supporting universities in Liverpool to create a local alliance.

As well as working with partner organisations, we scale services within the PCN to address need. For example, we developed South Sefton Access Service, a GP-led service, supported by ARRS practitioners, which adds 35,000 on-the-day appointments annually for acute and minor illness. This model enables patients to be seen in their own or a neighbouring practice, and 84% of patients said they were extremely likely to recommend the service.

Improving patient pathways

In creating new services through collaboration, we have been able to improve the patient pathway.

One example is our work on primary mental health services. We introduced new therapy programmes using ARRS funding to complement services delivered by partners in the VCFSE, mental health (MH) and community providers. When we introduced a MH forum to strengthen relationships between providers and better join-up services for patients, we identified issues with existing referral processes.

So, we led a programme with Mersey Care, Talking Matters, drug and alcohol services and charity Sefton Council for Voluntary Service (CVS) to establish a single referral pathway across providers to consolidate 14 referral routes into one. 

This helped to ensure patients are directed to the right service first time. It also removed confusion for referring clinicians around differing services and multiple routes of access. Now referrals are managed via a single ‘doorway’.

Outcomes

We launched our new mental health pathway in November 2023. This new integrated care pathway allows referrals to 10 services on one managed referral form and, by April 2024, average referral rates were 70 patients per week.

The new referral form includes providing consent to onward referrals, which has resulted in rejected or inappropriate referrals decreasing from 7% to zero. This more timely and efficient access to care has improved the quality of referral content and patient experience, enhanced communication and reduced workload and frustration for GPs.

Our EHAH service has also been a success. In the year ending 31 October 2024, our EHAH care co-ordinators met with just over 1,000 patients. As trusted assessors, they can order minor adaptations that help reduce the risk of falls and enable older people to retain independence in their own homes. They have made just over 2,000 referrals to services such as occupational therapy, befriending, and fire service. 

This proactive model of care has led to a reduced demand on hospitals. In the year before implementation, there were 1,575 hospital admissions. This was reduced by 26% in the first full year of service. In year two, it dropped again to 1,089, which is a further reduction of 7%. So far, there has been an overall reduction of 31%.

The ACEs recovery programme has resulted in participants changing behaviours, such as reducing unhealthy drinking or drug-taking. Pre-engagement, the average score on the Rosenburg self-esteem scale was 13. Post-programme, this rose to 16.2 (below 15 suggests low self-esteem, 15-25 within normal range). 

Since November 2022, there have been 838 referrals and 743 of them have been offered health and wellbeing coaching, signposting and onward referrals. To date, 332 have successfully completed the ACE programme, with three having secured jobs and two going to university as a result.

Collaboration

Being outward-facing has helped us build credibility with partners and motivated those partners to help us develop our services. 

We have worked to develop strong relationships with our place-based commissioners – who, in turn, recognise the opportunity of PCNs and the challenges facing general practice, particularly with respect to sustainability and estates. Commissioners are invited to attend our executive committees and PCN oversight group, which has helped open doors, build relationships and collaborate to explore innovative opportunities. 

The same principle applies to our engagement with patients and groups representing patients. We’ve spent time ensuring we co-produce our services and respond to patient feedback.

Our focus on integration and partnership working has been critical to delivering services and we are proud of all we’ve achieved.

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