What is a Primary Care Network?
A Primary Care Network (PCN) is a group of practices working together with a range of multi-disciplinary professionals across the primary care sector to offer more personalised, coordinated health and social care to everyone.
By working together, we can provide a wider range of services and allow our GPs to focus where their specialist clinical input is most needed.
In February 2019 GPs were presented with a new contract as part of the 5 year Forward View. This contract encourages GP Practices that are geographically aligned to come together to form Primary Care Networks (PCNs). These are not legal entities as such but there is an agreement between these Practices to work together and share new resources that will be available through the new contract.
Who are we?
Mid Chiltern PCN was set up on 1st July 2019, its population is approximately 43,600 patients made up of 5 Practices (Amersham Health Centre, Hughenden Valley and Chequers Surgeries, John Hampden Surgery, Rectory Meadow Surgery and The Prospect House Surgery).
The individual surgeries are still operating in the normal way. What’s changed is that there is more access for patients to be seen by different members of the PCN multi-disciplinary team described below. Patients can also self-refer to the Social Link Prescribers as well as Health and Wellbeing Coaches using the online form on the ‘Self-Referral‘ page.
How do we work?
The Multi-Disciplinary Team
Mid Chiltern PCN team is made up of three groups which we call Pillars.
In February 2019, GPs were presented with a new contract as part of the 5 year Forward View; this contract encourages GP Practices that are geographically aligned to come together to form Primary Care Networks (PCNs).
These are not legal entities as such, but there is an agreement between these Practices to work together and share new resources that will be available through the new contract.
The first Pillar is the Pharmacy group. This team is made up of a Senior Clinical Pharmacist, Clinical Pharmacist, a Pharmacy Technician and a Pharmacy Care Coordinator.
This team focuses on:
- Working with care homes to ensure patients get the best out of their medicines.
- Reviewing patients with long term conditions e.g. Asthma, Chronic Obstructive Pulmonary Disease (COPD), Hypertension and Heart Failure.
- Working with the Health and Wellbeing Coaches to support patients in managing their long term conditions.
- Referring patients to the appropriate services e.g. When visiting a housebound patient who feels lonely, a referral to the Social Link Prescribers would be suitable.
- Delivering Covid-19 vaccinations programmes.
The pharmacy team’s main objective is to improve the wellbeing of care home residents, housebound patients and patients over the age of 65 by reducing the number of prescribed medications that they are currently taking.
The team performs structured medication reviews with the care home to ensure that residents are getting the correct medications prescribed.
This increases the quality of life for residents, reduces unwanted side effects, as well as cutting down on the time, and money wasted from unnecessary prescribing.
The Pharmacy team and the health professionals from the care home, GP’s and the patients’ family members achieve deprescribing by reviewing patients’ medications and effectively reducing polypharmacy.
The Pharmacy team are also working on improving patients’ access to healthcare with the Community Pharmacy Consultation Scheme (CPCS) for patients suffering from minor illnesses.
Meet the Team
Rimple Patel
Senior Clinical Pharmacist
Arjun Patel
Clinical Pharmacist
Bhavna Jothiraj
Clinical Pharmacist
Zeeshan Nathvani
Clinical Pharmacist
Sumaira Sajid
Pharmacy Technician
Kim Beattie
Pharmacy Care Coordinator
The second Pillar is the Health and Wellbeing group. The team is made up of Social Prescribing Link Workers, Health and Wellbeing Coaches and a Mental Health Practitioner.
Social Prescribing Link Workers help patients with non-clinical health concerns and connect them with community services and organisations that provide support.
Health and Wellbeing Coaches support patients to identify and achieve their health related goals, by making positive lifestyle changes to improve their overall health and wellbeing.
The Mental Health Practitioner supports patients by offering self-help strategies and signposting to mental health services as required.
Meet the Team
Julie Dennis
Social Prescriber / Team Manager
Sarah Hill
Senior Social Prescriber
Community Engagement Lead
Cari Paterson
Social Prescriber
Lorraine Brickell
Health and Wellbeing Coach
This Pillar consists of two teams:
The first team consists of the Care Coordinators and the PCN Business manager.
The Care Coordinators ensure that a patient’s health and care planning is timely, efficient, and patient-centred throughout the whole of their primary care journey.
This is achieved by identifying a patient’s care and support needs and exploring options to meet these within a personalised care plan.
The PCN Business Manager’s role is to ensure the PCN team are delivering the highest quality health care across the 5 Practices.
Meet the Team
Bobby Pozzoni-Child
PCN Business Manager
Maria Bashir
Care Coordinator
The second team will consist of a Care Coordinator and Paramedics.
The Care Coordinators ensure that a patient’s health and care planning is timely, efficient, and patient-centred throughout the whole of their primary care journey.
This is achieved by identifying a patient’s care and support needs and exploring options to meet these within a personalised care plan.
The Paramedics will visit patients who are unable to attend the Practice, or those requiring an urgent home visit, to assess and advise whether further treatment or specialist care is required.