The Tardis Surgery is a member of the Moorlands and Rural Primary Care
Network
What are Primary Care Networks?
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 existing primary care services and enable greater provision of proactive, personalised, coordinated and more integrated health and social care for people close to home. Clinicians describe this as a change from reactively providing appointments to proactively caring for the people and communities they serve.
Each of the 1,250 PCNs across England are based on GP registered patient lists, typically serving natural communities of between 30,000 to 50,000 people (with some flexibility). They 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.
(Source www.england.nhs.uk/primary-care/primary-care-networks)
What is Moorlands Rural Primary Care Network (PCN)?
- Moorlands Rural PCN are a group of practices working together to focus on local patient care
- Our PCN consists of 7 practices, with a total population of approximately 39,500
- We have a strong leadership led by our 2 Clinical Directors and supported by our PCN Business Manager
- We work collaboratively with our local GP Federation who support core General Practice and help sustain its future. The federation are facilitating and supporting the recruitment of these new roles within our Primary Care Network.
What difference does the primary care network make to patients?
- We provide care in different ways to match different people’s needs. This includes access to advice and support for ‘healthier’ sections of the population, and joined up care for those with complex conditions.
- Extra services are offered locally at each GP Practice and there is no need for the patients to travel outside of their normal GP Practice area.
- We recruit extra specialist clinical staff to work alongside existing practice staff. Including Social Prescribers, Pharmacists, Dietitians, Occupational Therapists and Physiotherapists.
- We offer improved access to services and extend the range of current services available to patients.
Our Core Values
- We will demonstrate respect and have the high standards of integrity.
- We strive for continuous improvement.
- We welcome patient engagement.
Our Vision
- To bring better health care to residents in the Moorlands Rural.
- To improve the quality of life for patients.
Our Aims
- To develop the GP practice teams and make them fit to take the NHS into the future.
- To use data, technology and local knowledge to find the best health care solutions.
- To work together to ensure that we provide good care for both patients and staff whilst
- continuing to maintain the independence and individuality of each member practice
Moorlands Rural PCN Handbook (DOCX, 1.37MB)
Primary Care Network Staff here at The Tardis Surgery
Care Co-ordinator and Learning Disabilities Champion
Nicola Bradley
The overall aim of the Care Coordinator is to proactively identify and work with people, including the frail/elderly and those with long-term conditions, to provide coordination and navigation of care and support across health and care services.
The Care Co-ordinator ensures patient health and care planning is timely, efficient, and patient centred. The Care Co-ordinator has responsibilities for the coordination of the patient’s journey through primary care and secondary care.
This is achieved by bringing together all the information about a person’s identified care and support needs and exploring options to meet these within a single personalised care and support plan, based on what matters to the person.
Working together through a single point of access, the role will reduce and support the workload of GPs and other staff by supporting people to take more control of their health and wellbeing.
Nicola is also completing her NVQ level 2 Dispensing course, you will see her in our Dispensary.
Social Prescribing Link Worker
Coming soon.
Our social prescriber will talk to patients to understand their needs and discuss what help and support is available. If there is a problem that is not medical, the social prescriber can connect the patient to appropriate support and find ways for them to feel more in control of their health and wellbeing and a part of the community.
Support Time Recovery (STR) Worker
Diane Cox
The STR supports with assessing, signposting and providing short term interventions for mental health patients. Most work will take place in the community and will be a goals based approach. The STR will work with people who may experience severe and enduring depression and anxiety, severe mental illness such as bi-polar or schizophrenia or alternatively agoraphobia or OCD, providing support in a community or home setting.
Mental Health Practitioner
Eve Homer
- An ageless service and is able to speak to patients with a wide range of mental health needs.
- There to support patients to access the best service for their needs, by signposting or referring patients on.
The role is to provide a non-judgmental, supportive approach to help patients gain easier access to the right service to support recovery. Patients may have a one off assessment and be signposted to other mental health services or alternatively they may be offered follow up appointments to work on short term interventions.
First Contact Physiotherapist
Lorna Herbert
A typical First Contact Physiotherapist appointment involves assessment, diagnosis and first line management of musculoskeletal conditions.
This is a person-centred service, most appointments include self-management advice, social prescribing, and discussions about physical activity and fitness for work.
We do not provide a course of physiotherapy treatment but can refer patients for a course of physiotherapy treatment if it is clinically appropriate.
The service is only for patients aged 18+
Referral process Our First Contact Physiotherapist is:
Patients can direct access our service via their GP reception team simply by stating they have a relevant musculoskeletal condition. If any of the PCN clinicians think a patient would benefit from our input then the patient is either booked in to our diary by that PCN clinician or directed to book via their GP reception.
FCP Appointment Booking Criteria
| lnclusion Criteria |
Exclusion Criteria |
- Adults 18+
- All soft tissue injuries, sprains, strains or sports injuries
- Arthritis - any Joint
- Possible problems with muscles, ligaments, tendons or bone (e.g. Tennis Elbow, Carpal tunnel syndrome, ankle sprains)
- Spinal-related pain in arms or legs, including nerve symptoms (e.g. pins and needles or numbness)
|
- Acutely unwell
- Children under 18
- Medical management of rheumatoid conditions
- Women's health, ante-natal and postnatal problems
- Housebound patients
- Medication reviews
- Neurological / respiratory conditions
- Headaches
- Acute mental health crisis
- Patients who do not want to see an FCP
- Post-orthopaedic surgery
- Fractures
|
Clinical Pharmacist
We would like to welcome our new Clinical Pharmacist, Meh Jaheem
Our clinical pharmacist answers questions about the patient’s medicines and discuss how to get the best results for their health and lifestyle needs and support with:
- Medication side effects.
- Over the counter products.
- How to take different medications.
- Interactions with multiple medicines.
- Different ways to access prescriptions.
Our pharmacy team advise on medication in the local care homes too and complete Structured Medication Reviews (SMRs)
Pharmacy Technician
Alex Burton
Our Pharmacy Technician helps us to identify and prioritise patients who benefit the most from speaking to our pharmacists. Alex will liaise with community pharmacies and make the whole process of ordering and collecting prescriptions more efficient. Alex also helps to reduce waste and support safety audits.
You may see Alex helping in our Dispensary.
Our Pharmacy Technicians currently work on:
- DOAC reviews
- Safety Audits
- Blood Monitoring
- MHRA Alerts
- Self-care education
- Support with audits