During COVID, regular meetings where the three PPG representatives joined the clinical and management staff have been put aside.

The Clinical lead, Dr Amit Goyal discussed the last year and how things have changed since the three surgeries (now four after Whitehouse Medical Centre opened in December) formed the Primary Care Network (PCN).

There are now 42,500 patients in the network and there is now a data driven approach to care.

By looking across all the patients some key issues were identified.

These included mental health, hypertension and diabetes.

 

Mental health

By combining funding, the services of the Arthur Ellis Mental Health Support have been commissioned to support Children and Young People (CYP).

The key benefit is described in the lines below and means that each practice can direct patients straight to help.

https://www.arthurellismhs.com/

We’re using our corporate and other work to fund and drive our 1:1 service so people can access support when they need it without waiting lists or thresholds to entry.

This has made a big difference already, particularly during the pandemic.

 

Hypertension

As a result of each of the surgeries identifying patients between the ages of 18 -65 with hypertension, blood pressure monitors have been bought and our PCN Lead Nurse (based at Watling Vale Medical Centre) has been managing 50 patients from all surgeries offering pre-emptive treatment and advice and assisting patients to become medicine compliant.

 

Diabetes

A similar process of data analysis, followed by selection by each member practice, of suitable patients is being applied for diabetic patients.

 

Integrated Community Support Team (ICST)

A significant change in working practice has been the successful launch of the ICST.

The initial work was so successful that it has been pushed by the CCG into the other MK Networks.

Nurses and their colleagues have been regularly visiting those patients who for a variety of reasons have difficulty getting in contact with their doctor or visiting the surgery. This has previously resulted in a disproportionate amount of time taken up by medical staff and available appointments.

Additionally, the team work with more vulnerable people who have been recently discharged from hospital and who might be at risk of readmission.

Collectively the team work to support patients to adjust the way they are living to help them improve their mental and physical well-being.

With referrals growing at about 20 patients a week the ICST members visit up to 360 patients at home and so far have given over 1600 vaccine injections.

We have been able to have this team because we are working as a PCN. 

 

Physiotherapy

The network has combined funding to provide a muscular/skeletal physiotherapist for patients.

 

Klinik

Three of the four practices are using Klinik. Klinik provides Online Access for patients using sophisticated Artificial Intelligence to triage requests.

Each practice is operating separately at the moment but looking forward there are ambitions to provide an Urgent Care Hub.

 

Flu Vaccination Programme

The PCN came together to deliver a joint flu vaccination programme.  This was especially important during 2020 while we were trying to keep our practices, and therefore patients and staff COVID safe however by working together, off site, we were able to deliver a much wider variety of appointment times making the 2020/21 Flu campaign much more accessible.

 

COVID Vaccination Programme

Individual practices were not permitted to take on sole responsibility for any part of the COVID vaccination programme, only when working as part of a PCN did this become possible.  By working together WSN PCN has been able to offer 1,000’s of COVID vaccinations to our collective patients and all within a reasonable distance from home.

Further, our ICST have been able to deliver COVID vaccinations to all the housebound patients and those resident in care homes.  This would not have been possible without a PCN.

Patient Education

As a PCN we worked with the Saxon Clinic to deliver a number of patient education sessions.  These have been paused due to COVID however we would hope to restart them once it is safe again to do so.

 

Face to face or just virtually face to face?

“Sometimes it works for preliminary purposes, but there are many times when a surgery visit can be so much more revealing”.

 

Additional Staff

To date, PCN working has provided us with access to the following new staff:

2 x Community Nurses working within the ICST

1 x Social Prescriber working within the ICST

1 x Occupational Therapist

1 x Physiotherapist

1 x Care Coordinator

2 x Pharmacists

2 x Physician’s Associates

None of these appointments would have been possible had we worked as four separate practices and all of these staff are in addition to existing practice staff.

During 2021/22 we hope to also have exclusive access to an Adult Mental Health Worker.

 

Funding

Primary Care receives 9% of the health budget.

Every time a patient avoids going into hospital due to preventative actions by their surgery, the benefit is not credited to the practice in any measured way.

The ICST savings are not reflected in funding.

Dr Goyal will be discussing with his colleagues what possible uses might be made of the resources, existing and potential, of the PPGs.

 

 

C Allerton

May 2021