Primary Care Networks

In Durham, there are 13 Primary Care Networks (PCNs) which are developing to deliver seven nationally defined service areas:

• Structured medication reviews (live).
• Enhanced health in care homes (live).
• Supporting early cancer diagnosis (live).
• Anticipatory (community) care (this is about helping people to understand their health and care needs, that of their families and to think about what this means in the future, how their life will be affected by, for example, ill health, frailty, and long-term health condition).
• Personalised care (this is about people having choice and control over the way their health and care is planned and delivered).
• Cardiovascular disease (case-finding).
• Locally agreed action to tackle inequalities that exist in our communities.

This requires:

• A wider range of primary care services available to patients, involving new staff roles such as physiotherapists, paramedics, mental health workers and social prescribers.
• Taking a proactive approach to health and wellbeing, including assessing the needs of the PCN population to identify people who would benefit from targeted support.
• Working with a range of partner agencies to improve health and care.
• Activity which helps to reduce ill-health and supports people self-care.
• Practice that promotes shared decision making with patients about their care.

PCN approach

Patients will continue to have a named GP, accountable for their care but may be supported and treated by other members of the extended team who can best meet their needs.

This approach has been informed by the success of collaborative work primary care has been undertaking during COVID and the COVID vaccination programme.

With dedicated support and funding, County Durham PCNs are utilising a 'Maturity Matrix', designed to build capacity, knowledge and skills relating to:

• Leadership, planning and partnerships
• Use of data and population health management
• Integrating care
• Managing resources
• Working in partnership with people and communities

Progress and outcomes will be measured using a series of checks.

Health outcomes

• Proportion of people with a learning disability on the GP register receiving an annual health check.
• Uptake of screening programmes (breast, bowel and cervical).
• Delivery of structured medication reviews.

Patient experience outcomes

• National GP survey (annual).
• GP contract / Primary Care Network Patient reported access measure – measure to be confirmed.
• Patients whose care has been discussed as part of shared decision making.

Workforce outcomes

• Number of GPs employed by the NHS (Clinical Commissioning Group level data).
• Number in full-time employment (FTEs), above baseline, in the Primary Care Network additional role reimbursement scheme.
• Proportion of providers with an outstanding or good rating from the CQC for the 'well led' domain.