Stratford Collaborative PCN

Since the NHS was created in 1948, the population has grown and people are living longer. Many people are living with long term conditions such as diabetes and heart disease or suffer with mental health issues and may need to access their local health services more often.

To meet these needs, GP practices are working together with community, mental health, social care, pharmacy, hospital and voluntary services in their local areas in groups of practices known as primary care networks (PCNs).

PCNs build on the core of current primary care services and enable greater provision of proactive, personalised, coordinated and more integrated health and social care. Clinicians describe this as a change from reactively providing appointments to proactively care for the people and communities they serve. Where emerging PCNs are in place in parts of the country, there are clear benefits for patients and clinicians.

PCNs are small enough to provide the personal care valued by both people and GPs, but large enough to have impact and economies of scale through better collaboration between GP practices and others in the local health and social care system.

PCNs are led by clinical directors who may be a GP, general practice nurse, clinical pharmacist or other clinical profession working in general practice.

We want to support patients to make informed decisions about their health care and to connect them to most appropriate health or social care provider to ensure health care that is timely safe and all encompassing.

Active Monitoring provided by Mind provides supported self-help to patients dealing with mental health issues. This is in the form of a free, one-to-one guided programme with up to 6 sessions. This is different to counselling but uses counselling-based skills to support.

The first session will be 40 minutes to assess what support is required, the following sessions will then be 20-30 minutes addressing the identified support. Signposting to other services will also be provided if further support is required.

You can self-refer for this service using this form. You will initially be contacted to triage your referral and to discuss how the service can best help you.

Advanced Care Practitioners (ACPs) assess, diagnose and monitor complex conditions through examinations, testing and prescribing medicines. The role supports teams throughout the practice including duty doctors, frailty nurses, and performing home visits. Leading our community frailty support.

Care Co-ordinators help you to navigate the health and care system as well as supporting co-ordination of some primary care services. They are skilled at reviewing patients’ needs and providing personalised care: signposting to relevant services; promoting patients’ social wellbeing; and spending time with patients to find what best meets their needs. Support can be regarding anything from bereavement to loneliness and is aimed at connecting your health and your social life.

Care Co-ordinators are part of the practice’s support network and help patients to focus on their strengths, needs and aspirations but can also refer to Health and Wellbeing Coaches and other professionals where appropriate.

You can self-refer for this service using this form. You will initially be contacted to triage your referral and to discuss how the service can best help you.

Children and Young Persons (CYP) Mental Health Support is offered in practice and is a referral based system. Referrals can be made for anyone between 12-19 years old, who has had 2 GP appointments in the last 12 months. We understand waiting times for mental health support can be longer than expected, this additional role helps in primary care to lessen the stresses of waiting.

Clinical Pharmacists are engaged in multiple activities and you will most likely interact with them in the form of a medication review. In these reviews, they will ensure the appropriate blood tests and monitoring has been completed for your medication and review your current medication for appropriateness. This is your chance as a patient to have an in-depth discussion about your medication and any questions or concerns.

They have a strong relationship with your GP and any suggestions for your care will be as a multi-disciplinary approach. Queries about medication can also be directed towards clinical pharmacists

First Contact Physiotherapists in general practice are experts in musculoskeletal conditions. They are able to assess, diagnose and treat a range of complex muscle and joint conditions – preventing the need for referrals to hospital. They can arrange swift access to further treatment, investigations and specialists when needed.

They can help with:

• Diagnosing and treating muscular and joint conditions
• Advising on how to manage your condition
• Referrals on to specialist services

Frailty Nurses work within the care homes in Stratford-upon-Avon and are supported by a Care Coordinator. They undertake a weekly ward round in each care home, reviewing residents with acute illness to avoid unnecessary hospital admissions.

New residents and residents discharged from hospital are reviewed by the nurses and they support care homes in delivering palliative care. All their work creates strong networks across primary care, local care homes and community teams.

GP Assistants work under the guidance of a nurse or another healthcare professional. They help with routine health checks and provide patients with general health and wellbeing advice.

They can help with:

• Health checks, such as blood pressure monitoring
• Vaccinations and injections
• Phlebotomy – Blood tests

They are also able to assist the GP with pulling together information require for specific forms that need completing.

Health and Wellbeing Coaching is a service that puts the focus on what matters most to you. They have the time within appointments to support you to set goals and aspirations and empower you to improve and self manage your health and wellbeing, they do this through coaching and motivation techniques. The service offers one-to-one appointments within practice and also a group lifestyle clinic.

They can help with:

• Devising personalised care plans to encourage healthy eating and exercise
• Weight Management
• Lifestyle changes
• Managing long term health conditions
• Managing chronic pain
• Low mood

You can self-refer for this service using this form. You will initially be contacted to triage your referral and to discuss how the service can best help you.