Southport and Formby Primary Care Network is the provider of a number of workstreams. Read the information below to find out more about our work.
Complete Care Community: Complex Lives- fewer snakes, more ladders.
Southport and Formby Primary Care Network (PCN) covers a coastal population of mixed demographic but with undoubted inequality located in areas of Central Southport. The Chief Medical Officer’s Annual Report 2021-Health in Coastal Communities highlights the issues facing coastal populations and in Southport we recognise the impact of deprivation, physical and mental illness, substance misuse, homelessness, low quality housing, migrant population and seasonal employment are having on health outcomes. Our intended focus on inequality in Southport and Formby PCN is the population segment that experiences many of these risk factors requiring disproportionate support but still suffer poor outcomes - those living with Complex Lives. The Complex Lives population cohort defines those who represent some of the most marginalised and complex individuals in our services.
Complete Care Community: Aims
Our aim as a proposed demonstrator site is to develop a collaboration of stakeholders and patients with Complex Lives. This collaboration will test and document how partner agencies can re-calibrate their focus, language and attitudes, to improve service delivery for the complex lives population. We aim to do this through service user engagement and co-design and in a in a way that allows other sectors nationally to titrate our findings and meet exactly their own local need with no or minimal additional expenditure.
Enhanced Health in Care Homes
The Enhanced Health in Care Homes (EHCH) team work with care home patients and staff to ensure residents are receiving the best care possible. The EHCH model moves away from traditional reactive models of care delivery towards proactive care that is centred on the needs of individual residents, their families and care home staff. Such care can only be achieved through a whole-system, collaborative approach. Our team delivers the National Framework for Enhanced Health in Care Homes.
We provide reviews of individual needs in conjunction with families and carers via the Comprehensive Geriatric Assessment. We also implement and review Advanced Care Plans and take part in multidisciplinary team meetings, supported by local GPs and Consultant Geriatricians.
Early Cancer Detection
We’re working with GP practices across the region to improve the rates of early cancer diagnosis. The PCN Cancer and Practice Engagement Lead regularly meets with GP Cancer Leads across Southport and Formby to look at cancer screening and referral rates, and how we can standardise practice across the PCN.
Linking in with the Southport MacMillan Cancer Centre, the PCN also funds 4 Cancer Link Workers who offer emotional and practical support to patients with a new cancer diagnosis. Through a one-to-one consultation, the Cancer Link Workers can provide a listening ear to patients or their carer, helping to address any non-clinical worries or concerns they may have by signposting or referring to local and national support.
Our team of Clinical Pharmacists provide support across the area to complete structured medication reviews, ensuring patients are receiving quality prescribing. They work with staff in care homes as well as support teams for house-bound patients to deliver better medicine safety, better monitoring of medicines and better prescribing. The Clinical Pharmacists are also working to educate GPs on best practice when prescribing medication.
The team are currently working on a project to improve the early detection rates of Atrial Fibrillation (AF), as well as working with local community pharmacies to improve the diagnosis and treatment of Hypertension.
Community Pharmacist Consultation Service (CPCS)
The NHS Community Pharmacist Consultation Service (CPCS) was launched by NHS England and NHS Improvement on the 29 October 2019, to facilitate patients having a same day appointment with their community pharmacist for minor illness or an urgent supply of a regular medicine, improving access to services and providing more convenient treatment closer to patients’ homes. The GP practices of the PCN are actively referring patients to this service and this is helping to alleviate pressure on GP appointments and emergency departments, in addition to harnessing the skills and medicines knowledge of pharmacists. Should the patient need to be escalated or referred to an alternative service, the pharmacist can arrange this.
Social Prescribing Link Workers
Aiming to address patients’ needs with a holistic view, the Social Prescribers Link Workers provide non-medicated prescribing. GPs in Southport and Formby can refer patients to the service and our team will assess the patient and offer practical and emotional support alongside signposting to services that may be able to help them improve their health and wellbeing. We know that a person’s health can be influenced by a whole range of social, economic or environmental factors, social prescribing takes these factors into account and aims to support individuals to take greater control of their own health by adopting a person-centred approach.
Mental Health Practitioners
The service aims to provide non-urgent mental health assessments. Patients are offered a 30 minute assessment from which a plan is formulated. Depending on what is clinically required, patients may be offered medication advice or changes, brief medical interventions or may be sign posted to appropriate local services.
The PCN is currently in talks with Alder Hey Children’s Hospital to be able to offer a specific Children’s Mental Health service for young people in the Southport and Formby area.