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 2022/23

The North and West PCN has invested One Herefordshire funding to employ a full time Care Home Lead Co-Ordinator, who will support the delivery of the Enhanced Health in Care Homes contract. Supported by our PCN Care Co-Ordinator, they will be the first point of contact for the care homes linked to our Practices, work closely with the Care Home Leads of each Practice, supporting the ward rounds and MDT meetings. We have also employed a part time Dietetic Assistant Practitioner, who is providing nutritional advice to homes, and has held training sessions with home baked goodies which 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. 

The Wellbeing Team has continued to deliver group consultations to support patients with fibromyalgia to feel more confident to manage their own wellbeing and are progressing the setting up of a Peer Support Group, which through the sessions has been identified as a gap in provision in our area. 

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 has invested in their home visiting Paramedics service, which is providing additional resilience to our practices by delivering on the day visits, where a GP would ordinarily attend. 

Key focus areas for the next year:

Further develop and deliver on the Health Inequalities Programme for the PCN with the Wellbeing Team, designing and delivering group consultations for a cohort of patients. The Team has already delivered this on a face-to-face and virtual basis, which has proved successful. Further sessions are being planned.

Work collaboratively with Wye Valley Trust to look at how the District Nursing Team and our home visiting Paramedics could complement each other, making every contact count and avoiding duplication of visits to our patients.


Key People:

Dr Edward Conquest 
PCN Clinical Director

Hannah Hope
PCN Development Manager