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Primary Care Network demonstrates significant commitment to elderly population in award nomination

A Primary Care Network (PCN) within NHS Vale of York Clinical Commissioning Group is working collaboratively to generate improved health outcomes for patients in line with the NHS Long Term Plan. This work has resulted in the PCN being nominated for a National Association of Primary Care award.

South Hambleton and Ryedale PCN covers seven GP practices, serving a combined total of 35,000 people. Their locality spans a large rural area to deliver a wide range of services to a predominantly elderly population. 

Evidence of improving patient services since becoming a PCN include:

  • Establishment of a new dementia co-ordinator post the first post of this type in the Vale of York.
  • Support from the Parkinson’s’ Society to establish a new community nurse working collaboratively  with the acute specialist nurse to improve support for patients in this rural locality
  • Increased prescribing reviews amongst elderly population
  • Partnership working with York Teaching Hospital resulting in more patient reviews out of hospital and support for patients at home.
  • Development of an anticipatory model of care for frail elderly patients in the community, including support from a Consultant Geriatrician
  • Co-ordination of services for the PCN’s frail elderly population through a new Care Co-ordinator role
  • Piloting a rapid cancer diagnosis pathway

Dr Paula Evans, Clinical Director of South Hambleton and Ryedale PCN said: “In one of many examples the care co-ordinator supported a lady with advanced cancer; linking care plans from the specialist community palliative care nurse with the GP, facilitating contact with the local support centre when they struggled to get in touch with the family, visiting the lady at home and helping the individual to register for other local support such as community transport for hospital visits.

“The care coordination work in particular releases more time for GPs to focus on their patients often complex clinical needs, with the reassurance that their holistic needs are also being addressed.

 “Within four months of implementing the care co-ordinator role, 774 patients had a risk assessment status coded (red, amber, green) to help prioritise complex care support across the practices and received multidisciplinary team input.”

The PCN award for which South Hambleton and Ryedale PCN has been nominated for intends to recognise an ‘emerging primary care network that has made outstanding progress and plans in line with the vision for PCNs in the NHS Long Term Plan and GP contract.’

Dr Andrew Lee, the CCG’s Executive Director of Primary Care and Population Health said: “The nomination for a National Association of Primary Care award is well deserved and true credit to South Hambleton and Ryedale PCN for their innovation and efforts. It is fantastic to see how these health professionals collaborate with other health partners locally to serve their patients better. Their progress as a clinical network this year has been truly remarkable, particularly given the challenges of rurality and the small size of the locality. They are an exemplar and have much to share with other PCNs about their approach and their journey to date.”

The winners of the National Association of Primary Care awards will be announced at an awards dinner on 9 October 2019.

For more information on the six Primary Care Networks within the NHS Vale of York Clinical Commissioning Group, visit the CCG’s website: https://www.valeofyorkccg.nhs.uk/about-us/primary-care-networks/

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