PCN Services

Frailty Care co-ordinators help to co-ordinate and navigate care across the health and care system, helping people make the right connections, with the right teams at the right time. They can support people to become more active in their own health and care and are skilled in assessing people’s changing needs. Care co-ordinators are effective in bringing together multidisciplinary teams to support people’s complex health and care needs.

They can be an effective intervention in supporting people to stay well particularly those with long term conditions, multiple long-term conditions, and people living with or at risk of frailty.

A Cancer Care Coordinator works as a key part of the PCN multi-disciplinary team.

They are a key link to the people whose care we are supporting, operating as a go to person to ensure that their care is seamless. Care Coordinators provide extra time, capacity and expertise to support patients in preparing for or in following-up clinical conversations they have with primary care professionals.

The Cancer Care Coordinator works closely with the Clinical Leads and other primary care professionals within the PCN to make sure that appropriate support is made available to them and their carers, and ensuring that their changing needs are addressed.

The Cancer Care Coordinator is involved in increasing screening uptake and works closely with various practice teams to identify and work with groups and individual patients to increase uptake and provide, co-ordinate and navigate the appropriate care and support for patients across the PCN.

This includes achieving and exploring all options of support, completing a cancer care review based on what matters to the patient, assisting them to access services and identify any support they require, understanding and managing their own health and wellbeing.

Dementia Care co-ordinator will help to co-ordinate and navigate care across the health and care system, helping people make the right connections, with the right teams at the right time. They can support people to become more active in their own health and care and are skilled in assessing people’s changing needs. Care co-ordinators are effective in bringing together multidisciplinary teams to support people’s complex health and care needs.

They can be an effective intervention in supporting people to stay well particularly those living with Dementia & Alzheimers.

Social prescribing link workers connect people to community-based support, including activities and services that meet practical, social, and emotional needs that affect their health and wellbeing. This includes connecting people to statutory services for example housing, financial and welfare advice.

Social prescribing works particularly well for people with low level mental health needs, who feel lonely or isolated, with long term conditions and complex social needs.

Social prescribing link workers work collaboratively across the health and care system, targeting populations with greatest need and risk of health inequalities. They collaborate with partners to identify gaps in provision and support community offers to be accessible and sustainable.

ACPs are highly trained professionals with the knowledge and skills to take on wider roles caring for patients.
They have advanced qualifications (such as a Masters degree) and the experience to work independently without direct guidance from a superior, although they are still supervised and work as part of a clinical team. They come from a range of professional backgrounds such as: nursing, midwifery, physiotherapy, pharmacy, paramedicine and occupational therapy.

What do ACPs do?
ACPs can manage your care in partnership with you and your carers. They’ll listen to your concerns and in partnership with you, make decisions on the next steps to make sure you get the care you need. They can prescribe some drugs, order tests, organise treatment and work out the best treatment plan with you. You might meet them in your GP surgery, on a hospital ward or in the accident and emergency department of your local hospital.

What’s so different about advanced clinical practice and other specialists?
Advanced clinical practice is quite different from specialist practice. Specialists are experts in their chosen clinical area, for example in diabetes or asthma care. ACPs work across subjects as they have the advanced knowledge and skills to look after your care as a whole.

How does this affect me?
You may be asked if you agree to be looked after by an ACP. Usually, this is because they are likely to offer excellent all-round care for your particular circumstances. If you are not willing, you can ask for a different kind of healthcare worker to look after you.

Physician associates (PAs) are healthcare professionals with a generalist healthcare education who work alongside doctors and surgeons providing medical care as an integral part of the multidisciplinary team. PAs work under the supervision of a named senior doctor (such as a named General Medical Council registered consultant or general practitioner) but can work autonomously with appropriate support.

What can a physician associate do?

PAs are trained to work within a defined scope of practice and limits of competence to perform the following duties:

• taking medical histories from patients
• carrying out physical examinations
• seeing patients with undifferentiated diagnoses
• seeing patients with long-term chronic conditions
• formulating differential diagnoses and management plans
• carrying out diagnostic and therapeutic procedures
• developing and delivering appropriate treatment and management plans
• requesting and interpreting diagnostic studies
• providing health promotion and disease prevention advice for patients.

These FCP services offer patients access to an expert Physiotherapist at their very first contact in their GP practice. This ensures patients receive expert assessment and advice for their muscle, joint or bone condition and frees up time for GPs to help patients with other, more medical problems.

The vast majority of musculoskeletal first contact practitioners are physiotherapists with enhanced skills. They can help patients with musculoskeletal issues such as back, neck and joint pain by:

• assessing and diagnosing issues
• giving expert advice on how best to manage their conditions
• referring them onto specialist services if necessary.

Patients with back and joint pain, including conditions such as arthritis, will now be able to contact their local physiotherapist directly, rather than waiting to see a GP or being referred to hospital. Patients can also see a physiotherapist by speaking to the GP practice receptionist or by being referred by their GP.

By making it easier for patients to access physiotherapist, patients will have quicker access to diagnosis and treatment, helping them to manage their conditions more effectively and recover faster, so they can get back to normal life quickly. They will help GPs to manage their workload more effectively, and reduce the need for onward referrals.

A PCN Paramedic can be responsible for carrying out consultations to patients in practice sites or the central PCN Hub and for visiting patients in their place of residence who present with a wide range of minor illness, urgent and same day requests for treatment and chronic disease management; providing care for the presenting patient from initial history taking, clinical assessment, diagnosis, treatment and evaluation of care.