Patient Participation Group

Inclusive Health PCN Meeting Notes and Action Points of Wednesday, 6th March 2024

Meeting Agenda: 

• What is a PCN?
• Who we are
• Services and what we do
• GP Patient Survey and capacity and access

What is a PCN?

A Primary Care Network (PCN) is a collaborative approach to primary healthcare, involving multidisciplinary teams and integrated services to improve patient care coordination, population health, and overall healthcare efficiency. It emphasises teamwork, technology use, and patient engagement.

• Coordination of Care: PCNs ensure seamless care by coordinating services among healthcare providers through improved communication.
• Multidisciplinary Teams: PCNs create teams with diverse healthcare professionals to provide holistic and patient-centered care.
• Integration of Services: PCNs combine healthcare services, addressing preventive care, chronic diseases, mental health, and community resources for comprehensive patient support.
• Population Health Management: PCNs focus on proactive measures for the entire population they serve, including preventive care, health education, and addressing social determinants.
• Information Technology: PCNs leverage technology, like electronic health records, for efficient communication among healthcare providers and accessible patient information.
• Patient Engagement: PCNs actively involve patients in their care, emphasizing shared decision-making, education, and self-management of chronic conditions.

Who are we?

Our PCN consists of 7 practices, together we have the privilege of caring for almost 37,000 patients in West London. We are one of the smaller PCNs within west London, however what we lack for in size we make up for with enthusiasm and diligence, attacking the multitude of health inequalities within our practice populations with pragmatism, critical thinking and collaboration.

• Barlby Surgery
• Shirland Medical
• Queens Park
• Half penny steps health centre
• Dr srikrishnamurthy practice
• Mean while gardens
• The elgin

Executive Team

We have established a team put together from the best of the PCN has to offer, each member is representative of each practice within the PCN. We meet once a week to put together plans to improve patient care coordination, population health, and overall healthcare efficiency. The emphasis is on multidisciplinary teamwork to execute plans to improve health outcomes for our patients.

• Dr Akber Ali, Clinical Director (Half Penny Steps Health Centre)
• Dr Ed Farrell,  Associate Clinical Director (Shirleand Medical)
• Debbie McCarthy, Practice Manager's Representative (The Elgin)
• Abu Bakr Osman, Development Lead (Barlby Surgery)
• Mahmud Ferdous,  PCN Manager/ Digital Transformation Lead

Services

Out of hours GP/Pharmacist/Nurse appointments: 

We provide out-of-hours and emergency care in Kensington & Chelsea, operating seven days a week, including evenings and weekends, based at St Charles Integrated Care Centre and Violet Melchett Centre.

We conduct a monthly multidisciplinary team (MDT) discussion on diabetes, where clinical leads from PCN practices present cases for shared learning. Specialist diabetic consultants from Chelwest participate, offering real-time advice on managing challenging diabetes cases.

Tackling Neighbourhood Health Inequalities

Introduced in June 2021, CORE20PLUS5 targets health inequalities, focusing on the most deprived 20% nationally, specific population groups, and five priority clinical areas, including severe mental illness. TNHI service supports these efforts for equitable, high-quality care. 

SMIxI

Pilot scheme launching 31st March 2024 – The "SMI-Community Connection, Support, and Integration" (SMIxI) initiative targets individuals with Severe Mental Illness (SMI), those prescribed antipsychotic medications, and those on  learning disabilities register. This initiative aims to establish community connections, provide tailored support, and promote integration, emphasising a commitment to addressing diverse mental health needs within the community. 

The aim is to help patients with SMI to quit smoking, help with alcoholism, substance misuse and encourage regular exercise.

Cardiovascular Disease

We are currently in the process of trying to improve the cardiovascular health of patients within Inclusive Health PCN. Our aim is to identify the number of patients with potential cardiovascular disease by increasing the number of blood pressure readings for our patients.

Currently we have 4116 hypertensive patients from a total of 34,993 patients, our aim is to identify another 800 patients. This will hopefully allow us to prevent serious complications of heart disease, stroke and kidney disease.

By identifying high blood pressure early, patients can maintain better long term health outcomes and reduce the risk of premature death.

Outreach Clinics

So far this year we have run 4 outreach clinics for our patients to increase the uptake in flu vaccinations and childhood immunisation. 

We managed to vaccinate 61 people across our clinics ranging from the 6 in 1 vaccine, Rotavirus, Men B, Flu vaccine and MMR. We hold these clinics out of the Beethoven Centre.

This has been in response to the recent measles outbreak in our locality, but also our historically low uptake in childhood immunisation. Our ultimate aim is to understand why parents in out neighbourhood have such high vaccine hesitancy. 

We now have launched a Vaccination and Immunisation Scheme (VIS) where we are going through our registers and contacting the parents to try and understand what the hesitancy is and hopefully better educate the parents on the importance of immunisation.

FCP –First Contact Physio

We provide our patients with direct access to First Contact Physio appointments for MSK related issues, just over 400 appointments a month. Our FCPs work across the entire PCN, clinics are run out of ALL practices to provide equitable access to patients from every one of our practices.

This means that instead of seeing a GP with MSK related issues patients can see a specialist directly, if the patients require referral to secondary care or scans and x rays, our FCPs can sort that out on the day. 
The FCP service has quietly increased the amount of GP appointments available to our patients.

As with all our services there is still more room for improvement, we are working with practices to increase referral rates to the FCP service. The more efficient we become at referring to the service the more GP appointments will become available for everyone involved.

GP Patient Survey – Capacity and Access

On the surface the numbers look very favourable, however we aim to improve on this performance further, we have a few ideas on how to make improvement on the next slide. Please feel free to chime in and offer more options from a patients perspective.

See the latest results

PCN PPG

Purpose of PCN PPG

The purpose of the Patient Participation Group (PPG) is to collectively ensure that patients and carers across the PCC are involved in decisions about the range, shape and quality of services their practices provide.

The role of the PCN PPG includes: 

• being critical friends to each other Practice and sharing good practice 
• working together to advise on the patient perspective and providing insight into the quality of services 
• collaboratively work together to encourage patients to take greater responsibility for their own and their family’s health 
• carrying out research into the views of those who use the Practices 
• organising health promotion events and improving health literacy 
• ongoing communication with the patient population 

Constitution /TOR: Things to Consider

• How do we ensure we are a representation of the PCN population? Who is missing?
• What will be the name of the Group?
• How often should this group meet?
• How do we want to communicate with each other? 
• Aim, Priorities and Objectives
• Membership, Roles and Responsibilities?

NHS App

• Launched nationally January 2019
• Owned and run by the NHS
• Free to download 
• Safe and simple way for citizens to access a range of NHS services on smartphone, tablet or computer 
• Available to anyone 13 years and above, and registered with NHS GP practice in England or Isle of Man
• Your NHS number 
• Online consultation forms 
• GP and hospital appointments
• Notifications and messages 
• Repeat prescriptions
• NHS 111 Online 
• GP health record 
• Organ donation decision 
• Nominated pharmacy
• Electronic referral service eRS 
• Linked accounts 
• Personal Health Records 
• Health A-Z
• Be part of research 
• Find NHS services near you 
• Register for a GP online

​​​​​​​Learn more and download the NHS App​​​​​​​