PCN - Projects
Health Inequalities and Population Health
Pain Management
The programme aims are to offer greater support and an alternative approach to the management of chronic and/ or long-term pain experienced by service users, with the consideration of reducing high level opioid medication prescribed to such individuals.
Qualifying patients will be contacted by our PCN Social Prescriber who will give them an overview of the program and follow up with an invitation letter.
The program consists of a 4 weekly program.
Week 1- Consultation with Social prescriber
Week 2 – Good Boost group exercise program
Week 3 – Consultation with GP and social prescriber.
Week 4 – Good boost exercise program
Dementia Pathway
The Dementia Vision for Shropshire Telford & Wrekin ‘aims to provide people living with dementia with the support and resources they need in order to live their life to the fullest – and as they choose to’.
The vision identifies that every dementia journey will be slightly different to the next – some patients are diagnosed further into their dementia than others and some deteriorate quicker or have more complex co-morbidities; it is my role as ‘navigation lead’ to identify those differences and ensure a person-centred approach whereby the right support and information is available at the right time for the service user.
The service users are the person with the Dementia diagnosis and the carer.
To achieve this, link workers are already in place within the SES PCN to implement the vision; so, there is structure.
- We have DASS who take the initial referral from the GP and support the patient through assessment and diagnosis, stabilising medication and offering Cognitive Stimulation Therapy (7 sessions).
- We have a Dementia Link Worker to support the Dementia patient and engage with the local community. The Dementia Link Worker can also provide carer training – Lets Talk Dementia (2 sessions).
- We have the Shropshire Carer Support Team who sit within Adult Social Care and provide low level carer support, which includes carer training provision.
- We have the Admiral Nurse who supports carers with more complex situations or needs.
Women's Health Hub
Our practices and PCN teams are working towards better outcomes for women’s and young girls though promoting womens health hub. Our local projects have included increasing cervical cancer screening uptakes, advice and guidance around periods and nutritional support for menopause.
We have completed a pilot study targeting non responders of cervical screening using different types of language for different age demographics. We are going to roll this out to all practices within our network to reduce disparity between practices and at a PCN wide level. Practices can then use the funding to open up more screening clinics. STW have a high non responder rate and we would like to reduce this where possible within our network.
We would like to expand on our already started project around Menopause talks. In August2024, Dr Juliet Lyne did a menopause talk in Highley (area of high deprivation) that focused on providing information to women surrounding menopause and what to expect. The talk was well attended and well received. We are extending these talks through a ‘network roadshow’ in South East Shropshire PCN. We would like to work with the community teams to host these events and promote women’s health in the community throughout our PCN footprint.
We are also increasing capacity for our Dietician running some clinics on nutritional support for menopausal women. This will be for those detailed in our roadshow and clinics held at the practice locations.
Another area we are reviewing is the support offered for young persons and period poverty in schools. We are using our CYP social prescribers to offer support and working with school nurses to increase awareness of sanitary provision in more deprived areas.
Heart Failure at Home
In the UK, there are approximately 920,000 people affected by Heart Failure, with approximately 200,000 cases annually, and cases estimated to almost double by 2040. Furthermore, Heart Failure is accountable for 1 million bed days per year, 5% of emergency admissions and 2% of the NHS total budget.
Managing Heart Failure at Home has been a recent NHSE initiative hoping to improve patient outcomes and therefore reducing the subsequent pressures on the system. This has been suggested through using a combination of
- Remote Monitoring – helping to educate and empower patients in monitoring their signs and symptoms, understanding when to escalate, utilise differing methods of communication and help reduce avoidable admissions.
- Personalised and patient centred care – giving patients choice and control over the way their care is delivered, with shared decision making and supported self management.
- Increased integration of Primary and Secondary Care clinical services – using multidisciplinary teams to help enhance and coordinate patient care across systems
A targeted multidisciplinary service working to assess, educate, support and manage patients within our PCN with a new diagnosis of Heart Failure. Using a combination of GP, Clinical Pharmacist, HCA and Healthy Lives Advisor and Heart Failure CNS it is hoped that management is optimised, patients are supported and gain an ownership and control of their condition, in addition to gaining experience of the Additional Roles now working within Primary Care.
Approximately 50 patients will be offered to participate in the study, as those defined as having Heart Failure with a Reduced Ejection Fraction (HFrEF) diagnosed within the previous 6 -12 months. A series of appointments will be provided in the community with a mix of face to face and telephone consultations which will focus on individual personalised care, improving patient education and knowledge, in addition to ensuring patients are on maximal treatment and optimal quality of life.
Help to Stop Smoking
Nicotine Replacement Therapy, in collaboration with Shropshire Council – Support supplied through our Healthy Lives Advisors.
Sharing expertise and resources, to develop new services.
The PCN
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