How this PCN…delivers lifestyle clinics

Leamington Spa PCN is one of the six networks shortlisted for PCN of the year. Clinical director Dr Oliver Lawton shares the work of its PCN.

Collaboration and flexibility are pivotal for the PCN. North and South Leamington PCNs work together to bring an enhanced economy of scale for patients, whilst maintaining the option to work on a smaller population size where that feels more appropriate. We never lose sight of the fact that, very often, the best care looks like good old-fashioned, small-scale family medicine that may benefit from PCN support but not direct involvement.

We begin and end every PCN meeting by asking ourselves the same question: how can our actions today help achieve our unifying goal? Our objective is to make Leamington the healthiest Town in England. 

It is this approach – a commitment to be meticulous and relentless in our consideration of how to provide the best care possible – that led to our ‘hub’ model. As our strategy is to improve the provision of services in target areas, we often work with other provider organisations to develop hubs that deliver care.

The hubs provide an array of services including:

1. PCN lifestyle clinics: we don’t just talk about preventative medicine – we’ve committed resources and time to helping our patients avoid disease.  Anyone can access weekly group or one-to-one sessions with a GP, health and wellbeing coach, dietician, and psychiatrist.
2. PCN outreach clinics: taking primary care to our homeless patients.  A PCN-employed GP, dietician, and social prescriber work with the local drug and alcohol service which is our locally commissioned service, community outreach nursing and homelessness charities to wrap care around our significantly sized homeless population. Supported by public health, we help deliver shared goals to lessen the health inequalities experienced by this group.
3. Centralised medicines management and admin function: bringing economy of scales and best practice to support our GPs.
4. Specific PCN clinical support:  we respond to data and local knowledge to focus on areas of need, such as frailty, musculoskeletal, women’s health and learning disabilities. For example, we have a large number of care home beds and high unplanned admission rates to hospital so we redesigned and centralised care home provision. Three frailty nurses were seconded from secondary care to focus on proactive care, and we worked with the Federation to employ GPSI frailty GPs to offer enhanced care and weekly multidisciplinary team (MDT) meetings.
5. PCN fitness club: be it running, swimming, or walking, every weekday there is a PCN-led free fitness activity available to our patients.  Soon to come is our ‘Prambling™’ club, which will support new parents to get active.
6. Respiratory health connector service:  as the only Core-20 ward here, we were recently successful in a joint bid with secondary care to support our respiratory patients access the correct provision.
7. Leamington PCN health and wellbeing (HWB) festival:  attended by 7,000patientswho could access taster sessions for a plethora of exercise groups whilst learning about primary care services. The event ran synergistically with our District Council’s EcoFest.

Collaborative working

Covid meant public health, secondary care, councils, and third-sector organisations got around the table with us.  We have capitalised on and nurtured these relationships to create an environment of trust from which we can deliver services in unison. 

So, for example, we have worked with the District Council to develop a primary care estates strategy. Since 2019, three surgeries have been extended locally. This followed PCN-level discussions to ensure populations are best served, not just practices who happen to access Section 106 monies.

A PCN without a workforce strategy is one with no future, and a risk of growing a PCN is workforce destabilisation. We mitigate this risk by seeking to only employ roles which don’t exist currently in our practices.  There are over 60 PCN employees, and only two of them have moved from practices to the PCN.

Our approach to workforce helps us in other ways too. Our PCN lead nurse also works for our Health Education England (HEE) Training Hub.  This ensures a positive relationship with our local universities and training programmes to make Leamington an enticing place for healthcare professionals to train.  For example, we have a fantastic conveyor belt of trainee nurse associates who want to remain working in Leamington when they qualify.

Our approach has enabled us to shed the historic organisational biases that have hindered integrated working.  One of our clinical directors sits on the ICB and another works within the LMC and Federation to ensure a balanced viewpoint.

Lifestyle clinics

One of our great successes has been the creation of PCN Lifestyle Clinics.

Patients from any of the eight GP practices in the PCN may attend, either via referral by their GP or self-referral. Patients are free to attend the sessions in any order as well as repeat sessions as often as they like.

There are four sessions of around an hour covering: 

1. what is good health?
2. physical activity for health and wellbeing
3. behaviour change
4. diet and nutrition

The format of each session is the provision of information, questions, and then patient reflection. The information provided is short, non-technical and accessible, and questions from the participants mean that, to a certain extent, the material is tailored to the individuals in the group. All sessions are informal, non-judgemental, and supportive.

After each topic is introduced, patients are invited to reflect on the issues raised in relation to their own lives. They are invited to share their thoughts or doubts with the group or in pairs, but there is no pressure to do so. The aim is that participants can learn from others’ solutions and thinking.

Holistic approach

Although each session has a title, they tend to be holistic in approach. For example, the wellness wheel – covering social, occupational, spiritual, physical, emotional, environmental, and intellectual aspects of life – may be introduced so that when considering diet, participants are encouraged to consider all the factors that influence what they eat.

The setting of targets is lightly encouraged, and there are suggested ways of monitoring progress. Attendees say that they find the sessions motivating and helpful with some doing ‘homework’ each week and then returning to the session again.  Feedback has been that it can remove their sense of feeling ‘stuck’. 

After each session, there is a 45-minute segment of ‘walk talk walk’ (WTW) as well as a group for those who prefer to jog. There is no requirement that patients do the WTW – they are free to leave or do only part of it if they wish. Patients can also join the walk talk walk without having attended the sessions.

The sessions are run jointly by Dr Hussain al-Zubaidi and Dr Jo Fleming who is a health and wellbeing coach with input from others, such as dietician Sophie Turigel.  Both Jo and Sophie are employed by the South Warwickshire GP Federation and work with our PCN. Social prescriber Snay Gohil leads the WTW alongside Hussain and Jo.

Data on the impact of the lifestyle work streams is currently being gathered and will be published later this year.  We are seeing a reduction in BMIs and HBA1Cs, but we want to prove causation before publishing. 

Other outcomes

Our other initiatives have also been successful. 

The Outreach Clinic has had contact with over 30 homeless patients, and the data on health outcomes is currently under review and should be available by the end of the year. The service started January 2023. 

The Medicines Management Hub deals with a significant volume of queries each month. It takes more than 3,500 electronic prescription serviced (EPS) queries per month, over 900 care home medicine queries and more than 1,100 queries from community pharmacy queries.

Our PCN frailty nurses have completed a care plan for over 98% of care home residents, including treatment escalation plans and medication reviews. Data is being verified, but unplanned admissions have fallen by around 20% – and we are not even one year in.

The trajectory of our PCN’s maturation has surpassed all expectations. Harnessing a sense of collectivism, agility and positivity has improved patient care and provided resilience and efficiencies to our practices.

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.