Community Practitioner Alliance CIC are working with North Halifax Primary Care Network to provide a team of Acute First Contact Paramedics.

This is in line with the latest government strategy to introduce new and diverse roles into primary care, which will enhance access to timely medical assessment and provide a range of new skills.

The team of Paramedics are all highly trained in advanced physical assessment, minor illness and minor injuries and are predominantly used to provide home visits to our housebound patients.

The team has a fleet of fully equipped vehicles and are able to provide care in a timely fashion which will enable more patients to be treated in the community and avoid unnecessary hospital admission.

The GPs will assess patients as suitable for the service and will arrange the visit for the same day ensuring a timely response to acute medical problems.

The Paramedics have the full support of the GPs if they require any specialist advice or to arrange further investigations or follow up appointments. The team has been operating for a number of months and the feedback from this innovative service to date has been extremely positive.

Michelle – Ageing Well Practitioner

Our Ageing Well Practitioner is here to help people who are living with frailty. They will assess needs and design a plan to ensure that the right support is given to help live as well as possible.

The Ageing Well Service in North Halifax Primary Care Network has been continuously developing over the last 2 years. The aim of the role is to take a proactive approach to providing person centred care, helping patients to age well within their own home.

With a population size of approximately 7000 people over the age of 65 years this took some careful consideration, but after a review of the data, existing services, and the needs of this group of people our ageing well nurse was able to identify gaps in service and develop a model of care to address these needs in a holistic way. Patients with rising risks have been identified early through the data or via Clinician referrals and then offered a holistic assessment of needs and development of a personalised care and support plan. Staff have undertaken frailty training to help recognise and support problems early and multi-disciplinary team meetings have been set up occurring on a weekly basis with the wider health and social care team present to look at more complex cases and management plans.

The ageing well nurse predominantly completes home visits completing a holistic assessment of patient needs. Exploring the patient’s ability to managing their activities of daily living, medication management, nutritional intake and risk of malnutrition, ability to manage their health conditions, clinical observations, and social support needs. Look at what matters most to the patient and what is preventing them meeting their goals. Additional skills include assessment and management for minor illnesses, wound care, completing a basic medication review, advanced care planning discussions and DNACPR forms, assessing and ordering equipment, Carer support, lifestyle advise, signposting and referrals to other services such as social care, falls team, district nurses.

Other PCN teams involved in supporting the ageing well work include the social prescribing link workers, care co-ordinators, occupational therapist, and clinical pharmacy team.

We hope that this support will improve patient care and reduce GP visits and appointments, reduce hospital admissions and length of stay. We aim to reduce falls and improve prescribing of medications.

Review of support provided to date has shown patients feel more activated in managing their own health and wellbeing and we have seen a reduction in GP contacts and community service contacts.

Patient feedback has included:

“you brought out a little bit of the old spark in me”

“you offered me help when I was at my worst and I’ll never forget that. The service was caring and understanding – tell your boss it’s a 10/10 from me. Thankyou for getting me to a better place”

“at first I thought why do I need this. Good to know there is someone you can contact especially when there are a lot of barriers to accessing GPs”

If you feel you are someone or know someone that would benefit from an assessment by the ageing well team then please contact the GP surgery. Triaging will then take place and if appropriate a visit arranged.

Our Clinical Pharmacist (CP) team came into being in August 2020 when 4 CP started working for the Network. Meet the team:

Muddasser – Lead Clinical Pharmacist

Tahir – Senior Clinical Pharmacist

Zaine – Senior Clinical Pharmacist

Mehnaz – Clinical Pharmacist

Shazia – Clinical Pharmacist

Umayr – Clinical Pharmacist

The role of Clinical Pharmacists was introduced by NHS England with the aim of pharmacists taking a lead in medicines optimization. Medicines optimization is about ensuring the right patients get the right choice of medicines at the right time. This is a person-centered approach that improves safety, adherence to treatment, and reduces waste.

Main work streams for the team are:

Daily prescription queries

Structured Medication Reviews

Care Home prescribing

Reconciliation of hospital discharge summaries

Seasonal vaccination programs for care homes

The Clinical Pharmacists also manage long-term health conditions by carrying out:

Hypertension management clinics

Diabetes medication optimization clinics

Lipid optimization clinics

Any new medicines optimization projects

One key area of the contract is Conducting Structured Medication Reviews (SMRs) which is a comprehensive, holistic, patient-centered review that aims to support people with long-term conditions or who take multiple medicines, especially the elderly and people in care homes, to optimize their medication by improving health outcomes.

The Pharmacy team leads in developing relationships with members of the MDT to support integration of the pharmacy team across health and social care, including primary care, community pharmacy, secondary care, and mental health, by also working in partnership with commissioners, social prescribers, and local voluntary, community and social enterprise (VCSE) organizations and community groups. As part of the NHS agenda for Enhanced Healthcare in Care Homes, our Clinical Pharmacists are part of the MDT Team which engages in the care home ward rounds.

Our First Contact Physiotherapy service was launched in February 2020.

Meet our First contact Practitioners (FCP) in physiotherapy:

Rosie, Mags, Tom

Together they offer in excess of 80 hours of physio assessments per week.

FCP in physiotherapy receive referrals by our partner practices and from within the PCN team and assess and diagnose musculoskeletal issues. They provide the first point of contact whereby those who visit a GP for a musculoskeletal (MSK) problem will instead have an appointment with an FCP physiotherapist.

The opportunity to gain access to immediate specialist physio assessment is very well received by patients. It saves time for the patient (no more waiting for an appointment at the hospital) and GP surgeries (fewer GP appointments are required as reception staff can book patients directly with the FCP). Treatment/diagnostics can be administered more quickly and recovery is expedited. FCPs are highly qualified and experienced and able to assess, diagnose, offer treatment advice, and manage patients with MSK issues.

BENEFITS FOR PATIENTS IN THE NORTH HALIFAX PCN

Quick access to expert musculoskeletal assessment, diagnosis, treatment, and advice.

High satisfaction and patient experience ratings.

Shorter waiting times and fewer appointments than traditional secondary care referral.

Simpler logistics, reducing the need to travel, potentially avoiding missed appointments or suffering administrative errors.

Opportunity to get lifestyle and physical activity advice from a qualified professional.

Longer and more thorough appointments than GPs can currently offer.

More in-depth appointments mean patients feel listened to, cared for, and reassured.

Short-term problems are treated faster, preventing them from becoming chronic.

Opportunity for those with chronic conditions to get a good understanding of their condition and the exercises and lifestyle changes that will help improve it.

Quicker access to diagnostic imaging if clinically appropriate.

In addition to routine physio assessments, Mags and Rosie offer joint steroid injection therapy every month in practice setting, therefore reducing the waiting time for treatment by secondary care.

Meet our Mental Health Wellbeing Practitioner – Howard and Claire

A mental health wellbeing practitioner plays a crucial role in supporting individuals’ emotional and psychological well-being. They work closely with clients to provide guidance, coping strategies, and tools for managing various mental health challenges. These practitioners offer a safe and non-judgmental space for individuals to discuss their concerns and feelings. They may conduct assessments to determine the best course of action, provide psychoeducation to increase awareness about mental health, and offer evidence-based interventions such as mindfulness techniques, relaxation exercises, and stress management strategies. By fostering open dialogue and empowering individuals to develop resilience and self-care practices, mental health wellbeing practitioners contribute significantly to enhancing overall mental and emotional wellness.

Meet our Nursing Associate Jade.

She is highly trained and carries out assessments on most some of the vulnerable patients, i.e. those with learning disabilities and those residing in care homes.

Consists of Care Coordinators, Health and Wellbeing, Mental Health and Social Prescribing.

The Phlebotomist works in surgery by an appointment Tuesday – Friday 10:00 – 16:00. 

Patients told us that they would like phlebotomy in the afternoon.  We listened and invested in this very popular service. 

Meet our Podiatrist – Mohammed

Any problems with feet from infections and ingrowing toenails to problems walking to foot pain. Our PCN offers minor surgery every month.

Podiatry involves the assessment, diagnosis, and treatment of conditions related to the foot, ankle, lower limb, and its associated structures. It incorporates both conservative care for existing complaints, and corrective management for acute and chronic conditions.

Podiatrists can treat a wide-ranging list of complaints. Often, the presence of a conservative complaint can be linked to a problem that would benefit from corrective management and vice versa.

Podiatry also plays an important role in the management of long-term health conditions such as:

Diabetes

Peripheral neurological deficit

Peripheral vascular disease

Rheumatoid arthritis

During your initial consultation, the podiatrist will perform a full subjective assessment, listen to your complaint and details of the presenting problem. Documenting all medical history, including your general health and lifestyle.

They will then perform an objective assessment with your consent. Skin color, tone, texture, and temperature will be observed, alongside a vascular and neurological assessment to identify any deficit which may be underlying or linked to any pre-existing medical complaints.

If relevant, your podiatrist may also perform a biomechanical assessment, observing you standing, walking, and non-weight bearing. Ranges of motion will be assessed, and leg length observed. Hands-on examination of the affected areas may be necessary.

Your podiatrist will then discuss their findings, form a diagnosis and discuss treatment options available. They will talk through an appropriate management plan, including you in the decision-making process at every opportunity.

Our sample collection team (Keith and Ian) enables us to provide an afternoon blood taking service (phlebotomy).  They work tirelessly to provide the service 52 weeks a year.  This is not an NHS funded service but one that practices invested in.

Meet Bethany, our Health and Wellbeing Practitioner from South West Yorkshire Partnership.

Bethany provides assessments for Talking Therapies and if deemed suitable will book you for a course of Talking Therapy.