Primary Care Networks
OHP will provide infrastructure, leadership and development support for PCNs to make achieving requirements easier in future years.
Primary Care Networks (PCN) came into existence on the 1st July 2019 as part of the NHS Long Term Plan. They were formed to improve patient care outside hospitals, integrating community and secondary care services, aiming to provide world class health services in the community. PCNs comprise of general practice(s) working together providing services to 467,000 patients.
Primary care networks serve as an essential building block of every Integrated Care System with general practice taking the lead role in every PCN. Their purpose is to provide proactive, coordinated care to support patients to make informed decisions about their own health. The focus is mainly on prevention and personalised care (NHS England » Primary care networks).
OHP supports 10 PCNs across Birmingham and Shropshire serving a population size of 450,000, providing PCNs with leadership and strategic oversight striving to achieve excellence in patient care. We provide and facilitate a monthly CDE forum chaired by Dr Raj Pankhania, CD Shard End and Kitts Green, supported by Clair Huckerby, Consultant Pharmacist and Workforce Lead OHP and Anushree Choudhary, PCN development and Contracts Services Manager, OHP.
OHP Supported Primary Care Networks
The Alliance of Sutton Practices (ASP)
Includes three practices:
- Ashfield Surgery
- Hawthorne’s Surgery
- The Manor Practice
Clinical Director: Dr Fraser Hewett
PCN Management Lead: Leanne Hoye
PCN Lead Pharmacist: Santokh Sohal
Pharmacists: Sumeet Matharu, Katherine Brookes
Pharmacy Technician: Leah Downing, Alexis Spratt
Physician Associate: Naeemah Iffat, Smera Hussain, Francesca Bakhtiari
First Contact Physiotherapist: Joanne Leach
Care Coordinator: Nicole McArdle
General Practice Assistant – Natalie Sarjant
Social Prescribing Link Worker: Josephine Gornor-Pewu and Camillia Rhoden
Care Homes Supported:
- Abbeyfield House (Res)*
- Francis House (Res)*
- Green Lanes (Res)*
- Greenacres – Care Home with Nursing
- Hafod Nursing Home
- Hafod Residential Home (Res)*
- Lonsdale Midlands Ltd – Walmley Road (Res)*
- Marian House Nursing Home
- Mr Adrian Lyttle – Sutton Coldfield (Res)*
- Roxton Nursing Home
- The Gables (Res)*
- Sutton Park Grange
- Lisieux House (Res)
Kingstanding, Erdington and Nechells (KEN)
Includes seven practices:
- Kingsbury Road Surgery
- Bloomsbury Medical Centre
- The Nechells Practice
- Cotmore Surgery
- The Oaks Medical Centre
- College Road Surgery
- Small Heath Medical Practice
Clinical Director: Dr Jawahir Naik
Deputy CD: Dr Steve Gibbins
PCN Management Leads: Donna Cattell
PCN Lead Pharmacist: Jaspal Johal
Pharmacists: Suj Johal, Mangalpreet Singh, Baljeet Randawa, Vineet Sarin and Baljit Bakhshi
First Contact Physiotherapist: Karandeep Virdee and Gbemisola Ojebode
Paramedic: Richard Barry and Heather Cassidy
Dietitian: Melania Cox
Care Coordinator: Kaye Williams, Libby Hood, Trudy Harvey, Maxine Holmes, Riah Mayne, Danielle Jealous and Elspeth McGuigan
Social Prescribing Link Worker: James Griffiths and Azher Saeed
Care Homes Supported:
- Hurstway Care Home
- Liberty House Care homes Ltd (Res)*
- Manor House (Res)*
- Perry Tree Centre (Res)*
- SENSE – 296-298 Warren Farm Road (Res)*
- SENSE-Hawthorn Road
Shard Ends & Kitts Green (SEKG)
Includes seven Practices:
- Harlequin Surgery
- Mirfield Practice
- Church Road Surgery
- Hodgehill Practice
- Eden Court Medical Practice
- Schoolacre Surgery
- The Firs
Clinical Director: Dr Richard Edwards
Deputy CD: Dr Rajesh Pankhania
PCN Management Lead: Jennifer Fullford
PCN Lead Pharmacist: Damien Tang
Pharmacists: Avais Makhmood, Amritraj Uppal, Mahvish Mughal, Benjamin Gee, Hurfan Azam and Anudeep Dhillion
Pharmacy Technician: Katey McCorkell
Physician Associate: Shareen Bibi, Shanice Moncrieffe, Aniqah Mia and Jade Johnson
First Contact Physiotherapist: Sanjay Dahiya, Sopan Hatwar and Anthony Blisset
Paramedic: Thomas Latham
Care Coordinator: Philippa Conran and Lisa Hall
Social Prescribing Link Worker: Shazia Malik, Sharon Mullard and Heidi King
Care Homes Supported:
- 306-308 Packington Avenue (Res)*
- Accord Housing AssociationLimited – 1a West Avenue
- Aran Court Care Home
- Autumn Leaf House (Res)*
- Briarscroft Residential Care Home (Res)
- Greswold House (Res)*
- St Giles Care Home
- The Orchards nursing home
- Westley Brook Close (Res)*
- Bromford Apartments
- Berwood Court Care Home
- Hodge Hill Grange
- The Ridings Care Home
Moseley, Billesley & Yardley Wood (MOBY)
Includes six practices:
- Yardley Wood Health Centre
- Wake Green Surgery
- Greenridge Surgery
- Baldwins Lane Surgery
- Poplar Road Surgery
- Victoria Road Surgery
Clinical Director: Dr Matthew Jordan
Deputy CD: Dr Amanda Gough
PCN Management Leads: Sophia Raja and Gemma Mooney
PCN Lead Pharmacist: Arfaan Sultan
Pharmacists: Waseem Khan, Sukaina Bandali, Sadia Ahmed, Alia Ali, Veronica Quarton, Sanjeev Sharma and Marya Hussain
Physician Associate Apprentice: Rizwana Iqbal
First Contact Physiotherapist: Usman Zakari
Paramedic: Christopher Harte and Zoe Hearn
Care Coordinator: Chinny Mercy Onyebuchi, Cheryl Griffiths, Abbie Mae Heath, Jessica Rachel Pearce, Camilla Scheftelia, Saduf Parvez, Julie Schuppler and Kimberley Martin
Social Prescribing Link Worker: Tanwir Akhtar, Lauren Dooley and Susan Stanley
Dietitian: Jessica Foss
Care Homes Supported:
- 23 Trittiford Road (Res)*
- Anita Stone Court
- Ashley Lodge RH Limited (Res)*
- Barkat House Residential Home (Res)*
- Bramley Court Care Home
- Bramley Grove Care Home
- Chesterwood (Res)*
- Cole Valley
- Prospect House
- Evergreen (Res)*
- Forest Grange (Res)*
- Highbury Nursing Home
- Keo Lodge (Res)*
- Maycroft (Res)*
- Otterburn
- (94) Sandford Road (Res)
- (38) St Alban’s (Res)*
- Strensham Hill Care Home (Res)*
- Westholme (Res)*
- Newday Nursing Home
- Victoria Lodge Care Home (Res)
Bournville and Northfield (B&NF)
Includes Three Practices:
- College Green Medical Practice
- St Heliers
- Wychall Lane Surgery
Clinical Director: Dr Barbara King
PCN Management Lead: Daniel Hill
PCN Lead Pharmacist: Yvonne Murphy
Pharmacists: Catherine Lilly Boloursaz-Mashhady, Nawaz Mohamed, Nisha Farmah, Ban Aziz and Laith Kamel
Pharmacy Technician: Laura Mitchell, Patricia Broders
First Contact Physiotherapist: Enxhi Kumanti and Dilpali Kacha
Care Coordinator: Sabiul Hoque, Karen Antcliffe, Jayne Graham, Maria Ebinesan, Annabelle Hawkins, Michelle Murray, Halima Jamil and Assayed Dawood
Social Prescribing Link Worker: Annie Langrick
Care Homes Supported:
- Bourn View (Res)*
- Bournville Grange Limited (Res)
- Brain Injury Rehabilitation Trust – Bristol Road (Res)*
- Hasbury Care Home (Res)
- Ivybank Care Home (Nursing home)
- Lucton House (Res)*
- Selly Wood House (Nursing Home)
- SENSE The Old Coach House (Res)*
- Stennards Leisure Retirement Home (Frankly Beeches) (Res) *
- Stennards Leisure Retirement Home (KN) (Res)
- Trescott Road (Res)*
Weoley and Rubery (W&R)
Includes four Practices:
- Millennium Medical Centre
- Woodgate Valley Health Centre
- Weoley Park Surgery
- Leach Heath Medical Centre
Clinical Director: Dr Peter Arora
PCN Management Lead: Nicola Butler
PCN Lead Pharmacist: Parveen Ahmed
Pharmacists: Raj Sangha, Almas Rehman, Katrina Earle, Suky Sandhar, Rupinder Shambi and Hardip Kalirai
Physician Associate: Masrufa Miah, Alireza Mamdani, Grace Ipanga, Sonia, Sidhu, Sameerah Connor and Niamh Fallon
Care Coordinator: Jenna Davies and Nicola Butler
Social Prescribing Link Worker: Mundeev Kaur and Jackie Moore
Care Homes Supported:
- Bartley Green Lodge (Res)
- Greenlands View (Res)* LD
- Lonsdale – Bushwood Road (Res)* LD
- Ludford Road Residential Care (Res)* LD
- Oakview Care Home (Res/nursing)
- Redwoods (Res)* LD
- Sparrowfields (Res)* LD
- Tulip Gardens (Res) LD
Quinton and Harborne (Q&H)
Includes two practices:
- Lordswood Medical Practice
- Ridgacre House Surgery
Clinical Director: Dr Philip Saunders
PCN Management Leads: Angie Newton
PCN Lead Pharmacist: Parbir Jagpal
Pharmacists: Sharonjit Joall, Elaine Povey, Faiza Yahya, Julie Brooks, Ross McGill and Rita Devy
Pharmacy Technician: Colleen Lewis
First Contact Physiotherapist: Divya Shetty
Paramedic: Carly Jones, David Bayliss, David Davies and Mandy Strutt
Care Coordinator: Bronwyn Dare, Alison Wildman, Danneka Moore and Hannah Nicholls
Health and Wellbeing Coach: Alison Emeny
Social Prescribing Link Worker: Anna Walker
Care Homes Supported:
- Dimmingsdale Bank (Res)*
- Harborne House (Res)*
- Hightrees (Res)*
- St Joseph’s Home – Birmingham
Clinical Director: Dr Nitesh Mistry
South Birmingham Alliance (SBA)
Includes five practices:
- Doski Medical Centre
- Northwood Medical Centre
- Cofton Medical Centre
- Great Park Medical Group
- Rea Valley Healthcare Partnership
Clinical Director: Dr Nitesh Mistry
South West Shropshire (SWS)
Includes six practices:
- Church Stretton
- The Meadows
- Bishops Castle
- Craven Arms
- Portcullis
- Station Drive
Clinical Director: Dr Deborah Shepard
PCN Management Lead: Debbie Davies
Pharmacists: Eden Maxwell, Charlotte Lynch and Sandeep Jangra
Care Co-ordinators: Rachel McGregor, Alison Stewart, Sarah Worrallo and Rashed Choudhury
Social Prescribing Link Worker: Katie Hanson and Sharon Cochrane
South East Shropshire (SES)
Includes seven practices:
- Albrighton Medical Practice
- Alveley Medical Practice
- Bridgnorth Medical Practice
- Brown Clee Medical Practice
- Cleobury Mortimer Medical Practice
- Highley Medical Centre
- Much Wenlock and Cressage Medical Practice
Clinical Director: Dr Jessica Harvey
PCN Management Lead: Ella Butterworth
PCN Lead Pharmacists: Toyin Olajide Olukemi, Mei Kee Kok
Pharmacists: Nour Morjan, Gareth Harris and Doris Okafor
Pharmacy Technician: Julie Bates
Physician Associate: Megan Chowns
Care Coordinator: Louise Linning, Amy Hudson, Katie Kiely and Jo Weaver-Jackson
Health and Wellbeing Coach: Jessica Sawojka
Social Prescribing Link Worker: Joanne Aston, Rebecca Jennings, Abi Lowe-Werrell and Julie Gildie
Primary Care Network Services
1. Care Homes
Enhanced Health in Care Homes is one of the priorities for NHS England and Primary Care Networks have put in several services to ensure there is a joined-up care for the residents.
Our Health Partnership led on this piece of work on behalf of the Practices that are part of the partnership and have put several services in place starting June 2020.
A summary of the services:
- Each care home registered with each practice will receive a weekly check in call.
- The purpose of this initially is to establish if there are any issues (including those relating to medicines and End of Life care (EoL)), new diagnoses of COVID and to identify patients requiring urgent clinical input.
- Where issues are identified these are will be dealt with through the existing systems and processes.
It is important to note that there should already be systems in place for managing medicines related queries and issues. We have summarised these along with ongoing work on improvements below:
- We now have clinical pharmacists in every PCN (group of practices) who can support existing practice teams with medicines and prescribing related queries, this is already happening to some extent, we are working with the CCG to formalise communication channels.
- The PCN Lead pharmacists will work with their clinical colleagues in the Practices to ensure these systems to support medicines access and good medicines practice are in place.
- The Local Pharmaceutical Committee has shared details of each PCN Lead Community Pharmacist who can support us with relevant prescribing and medicines issues (including access).
- There is national ask for all prescribing where possible to be completed electronically and where appropriate to be converted to Repeat Dispensing.
- Implementation of guidance on medicines reuse in care homes provided where appropriate.
It is important to note that there should already be systems in place for personalised care planning and this remains the responsibility of the individual patients GP.
2. Social Prescribing
What is Social Prescribing?
At times we feel ‘unwell’, ‘out of sorts’ or ‘below par’ and a medical prescription is not the answer. What we are lacking is company, interests, or a change of scene to make us feel connected and motivated. Or perhaps we need counselling or more exercise to keep our bodies strong and our minds stimulated.
Our health and wellbeing starts with taking care of ourselves as best as we can.
Ask yourself:
- What do you need to help you feel more included?
- What could you do to feel happier in yourself?
- Do you want to make new friends?
- Are you aware of what is going on in your local area?
- Where are the exercise classes or social groups you could join?
That’s where social prescribing comes in!
Our free Social Prescribing service can provide you with a Social Prescribing Link Worker (SPLW) who will help you identify one or more activities to improve your wellbeing and support you in starting it.
How does it work?
One of our SPLW will meet with you to chat about your lifestyle and help you to identify activities or support that will benefit you.
The SPLW can help connect you to local services and activities to improve your physical and mental wellbeing:
-
- Counselling
- Arts and crafts
- Advice and guidance
- Addition support
- Physical activity
- Culture
- Eating Well
- Meeting People
Introducing our Social Prescribing Partners
The Active Wellbeing Society (TAWS) is a community benefit society and cooperative, working to develop healthy, happy communities living active and connected lives.
By working collaboratively with Our Health Partnership on our social prescribing programme, they bring about sustainable change on a social, environmental and economic level to our patients; to do the social knitting required to create stronger and more resilient communities and to support communities to identify, mitigate and remove the barriers that prevent them from living active and connected lives.
Once referred to them either by the surgeries or as a self-referral TAWS Social Prescribers will empower our patients to gain the capacity, resources and skills by working one to one or in a group carrying out indoor or outdoor activities, or by talking and befriending via phone calls.
If you are interested in this type of support, then please either ask when you are next in surgery or complete the attached Form to self-refer.
You are eligible if you are:
- Over the age of 16
- Need some support, guidance and encouragement to improve your mental or physical health and wellbeing –
- A patient at an Our Health Partnership GP Practice
First specialist social prescribing team in the UK based in Birmingham
Doctors across parts of Birmingham are able to direct patients who otherwise struggle to access support to a range of health-enabling activities such as art classes instead of medication in a partnership launched with health and social care organisation Turning Point.
The initiative is a UK first and will involve 25 GP practices managed by Our Health Partnership (OHP), one of the biggest GP partnerships in England, and a specialist social prescribing team run by Turning Point.
The aim of social prescribing on the NHS is to offer non-clinical alternatives in the community that can support health and wellbeing such as gardening, cookery, and volunteering to patients.
The Birmingham scheme will also relieve pressure on doctors who have been overwhelmed during Covid and now face a backlog of patients whose health issues may have worsened over lockdowns.
Patients will be referred to social prescribers – known as link workers – to help them improve their health, wellbeing, and social welfare.
What’s new about the Birmingham programme is the team of five link workers, managed by Turning Point, with a range of experiences in their respective fields will provide a significantly higher level of support than seen anywhere else before in the UK.
Each worker has specialist knowledge of how to support patients from specific backgrounds such as those with a learning disability, mental health problem, drug, and alcohol issue – or a combination of such challenges.
The multidisciplinary team will work together with existing link workers, local services and voluntary, community and social enterprise organisations across Birmingham.
This is to ensure people are supported to break down barriers, including stigma, in accessing whatever help they need. The joint working reflects the fact that health and wellbeing outcomes are influenced by a range of factors beyond clinical factors, from housing and job status to race and gender.
The service is part of an innovative approach to social prescribing and will work in partnership with The Active Wellbeing who already offer a universal social prescribing programme to patients across Birmingham.
OHP identified that they wanted something different to meet the unmet needs of their patient population. They have utilised the experience of Turning Point as a leading health and social care organisation with over 50 years’ experience.
Amy Stephenson, Head of Health and Wellbeing at Turning Point, said: “Having a personalised approach can have better results for groups that typically have poor health outcomes.
“Someone who has multiple health needs, such as drug problems as well as for those with a learning disability, may not realise their goals in life without the support that looks at the bigger picture of their health and wellbeing.
Many are passed between multiple agencies and services, each one only addressing a specific issue. Specialist link workers will be able to help people consider multiple issues, join the dots between existing support provision and provide a higher intensity, bespoke level of support.
“We’re really excited to be able to work with OHP and The Active Wellbeing Society in offering this specialist service and look forward to building on solid foundations.”
Dr Vish Ratnasuriya MBE and Chair of OHP said: “Prior to the pandemic, OHP wanted to start work towards addressing health inequalities further by creating a new role that reaches out and build relationships with people who struggle to access traditional care or fall between gaps in services.
“We are really pleased to launch our partnership with Turning Point in creating this specialist link worker role using their breadth of expertise. I look forward to seeing the impact on lives when specialist link workers connect, and build trust and relationships, and to begin meaningfully to address what matters to each person they see.”
Michelle Howard, Director of Healthy Communities, said: “We are excited to be collaborating with Turning Point and OHP, to provide practices and patients with a truly unique programme of support. In light of the past year, this has never been needed more and together we’re developing and delivering a new model of targeted patient support services”.
Turning Point is a social enterprise which has over 50 years’ experience of providing support for people affected by drug and alcohol problems, mental health issues, offending behaviours, unemployment, health and wellbeing social issues, and those with a learning disability to discover new possibilities in their lives. For more information, please visit www.turning-point.co.uk.
Social Prescribing in Shropshire
Shropshire Council provide the Social Prescribing Services to our South West and South East Shropshire PCNs. Details can be found on their website.
3. Building our Multidisciplinary Team