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GATESHEAD INNER WEST PCN FRAILTY SERVICE The frailty service promotes health and wellbeing , encourages self-care and delivers personalised health care in patients ’ homes , local surgeries and other community-based settings . The nursing team strongly believes individualised services close to home are the ‘ future required response ’ to managing the population ’ s health needs .
In the past year the team has received more than 700 referrals , with appointments offered to suit the patient . This has been achieved with just three team members .
The team covers five GP surgeries across eight miles but , despite this small area , social determinants of health and life expectancy differ significantly .
The aim is to avoid a ‘ postcode lottery ’ effect in the communities that are less engaged and less able to access healthcare within the PCN .
PCN assistant manager Samantha Iveson said the PCN is lucky to have a dedicated , forward-thinking nursing team . ‘ The frailty team deliver the gold standard in elderly care and promote NHS England ’ s 10-year plan of having patients cared for in their homes . The team has a big impact on surgery access and GP support , as well as favourable patient outcomes .’
HEALTHY HYDE COMPLEX CASE NURSES Strong , effective communication lies at the heart of this team ’ s success .
The complex case nurses aim to offer a consistent level of service for all patients . This means providing equity of care in the 13 care homes covered .
The Healthy Hyde PCN dementia case-management service cares for those living at home with dementia . A dedicated nurse will formulate personalised care and support plans to ensure patients receive the right care at the right time in the right place .
The team wants to offer a ‘ one-stop shop ’ and works with groups and organisations locally to address the health and social care needs of those living with dementia and their carers , from diagnosis until the end of life .
There is a full multidisciplinary approach , enabling the team to call on the urgent-action clinic or paramedic home-visiting service if needed . With a 20 % reduction in hospital admissions , the team ’ s proactive approach has proven an innovative and flexible way of working .
One care home manager said the team ‘ thinks outside the box when supporting the residents in our care ’, adding that the nurses ’; involvement in MDT meetings ‘ really helped the home get the right support ’.
THE ROYAL WOLVERHAMPTON NHS TRUST ’ S PCN
NURSING TEAM Identifying gaps within primary care services – such as some GP practices having much less nursing support than others – has led to a range of measures , including increasing the ANP workforce , training and upskilling nursing staff , and introducing a primary care nurse support team . The latter has taken responsibility for Covid vaccinations , vitamin B12 injections , cervical screening , wound care and other services .
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The team works closely with 17 care homes across Wolverhampton , and supports housebound patients , those living with a learning disability and those reaching the end of life . Training and support for care home staff has been provided , and an enhanced health in care home service introduced , which also delivers the GP home-visiting service .
The nurse-led care home team provides weekly ward rounds to the care homes registered with the PCN and supports staff and patients to reduce admissions .
In addition , dedicated mental health and sexual health nurses and multiple long-term condition clinics have been introduced . The team has also hosted clinics at a facility for people experiencing homelessness , as well as clinics for asylum seekers living in hotels .
The team were described as showing ‘ sheer determination and dedication to their role ’.
PRIMARY CARE SHEFFIELD DARNALL NURSING TEAM A key clinical area targeted by the nursing team has been cervical screening . In order to increase uptake , the team sought a low-impact approach for the practice but one that would support the South Asian population , which has the highest number of non-attenders .
The team set up a weekly drop-in service , with education and discussions offered to build trust and provide support . Any woman due a smear could attend , and the team targeted those on the non-responder register . Awareness in the community began to increase through word of mouth , texts and leaflets .
A social prescribing team member said : ‘ The drop-in is great for patients – they know an interpreter will be available if needed and they can turn up any time in a two-hour period . I ’ m always promoting it to patients .’
In the first year , non-attender uptake increased by 24 % and overall uptake by 33 %. Of previous non-attenders , 10 % were referred to colposcopy . The work helped the practice met its QOF target in 2022 for cervical screening , which , in previous years , had not been achieved .
TRACEY ELLIOTT , CLINICAL LEAD , SWIFT PCN NEW WAY
LEG CARE , BRISTOL Many patients who attend the leg clinic live in the most deprived areas in Bristol . They benefit from the location of this service in a community setting .
As clinical lead , Tracey Elliott has been a driving force behind the success of the project as well as the achievement of a healing rate that is 62 % above the national average . She often gives up her own time in the evening or at weekends so no one misses out on care .
Patients of all ages can access treatment for lower-leg ulcers in a community setting , with group sessions offering peer support . This has helped reduce the stigma associated with having leg ulcers . Partnering with Age UK has provided a link to these services , and Ms Elliott has been pivotal in building this relationship .
Promoting self-care has benefited patients and the wider system , reducing admissions and treatment costs , and improving patients ’ quality of life .
A staff member commented that ‘ Tracey is so dedicated to her patients and goes above and beyond ’, while a patient said ‘ feeling at ease and being treated with respect ’ made attending the clinic the ‘ highlight of my week ’.