North and West Primary Care Network

Supporting patients registered with practices in North and West Herefordshire: Kington, Weobley and Staunton, Mortimer (Leominster), Ryeland Surgery and Tenbury

Population: 51,227

...of Whom 23% are over 70

Practice staff: 95.87 WTE
PCN Team: 23 WTE

Covers: 430 sq miles

Carehomes: 18
435 beds

Major achievements during 2023/24

Our Care Home Lead Co-ordinator continues to support the delivery of the Enhanced Health in Care Homes contract. With our Dietetic Assistant Practitioner and PCN Dietitian providing nutritional advice to homes and leading training sessions with home baked goodies,this has been a great success. 

The PCN has continued to provide covid vaccinations throughout the autumn and spring to its population at the practice sites and at Earl Mortimer School in Leominster. 

Working in collaboration with the clinical lead at Tenbury, our Health and Wellbeing Coach and Senior Social Prescriber have delivered group sessions for patients who have recently been diagnosed with Stage 1 Hypertension. These are six week sessions, providing advice on their condition, nutrition and exercise with support from Active Herefordshire and Worcestershire, our PCN Dietitian and the community assets within Tenbury. 

 

Our PCN Dietitian and Dietetic Assistant Practitioner have supported the Integrated Care Board's Medicines Team in reviewing the Prescribing Guidelines for Oral Nutritional Supplements (ONS) for adults. They have also provided training to Herefordshire and Worcestershire's Pharmacy Teams on inappropriate prescribing to support driving down costs, whilst improving patient care through continuous improvement. 

The PCN's home visiting Paramedics provide additional resilience to our practices by delivering on the day visits where a GP would ordinarily attend and also provide continuity of care to some of our most vulnerable patients. 

Key focus areas for the next year:

Undertake a review with Public Health of our health inequalities for the PCN. Co-produce an updated action plan to take forward, working with Talk Community and through the Community Action Network meetings to support the communities and understand their needs. 

The Wellbeing Team are reviewing practice patient lists to identify those who are coded as a carer. They are then and reaching out to offer signposting to services or support from the Wellbeing Team Service. 

Key People:

Dr Edward Conquest 
PCN Clinical Director

Hannah Hope
PCN Development Manager