Annual review 2023-24

Our two Mental Health Occupational Therapists (MHOTs) started running clinics in January 2023. During 2023 they offered 1,740 initial and follow-up appointments as either telephone or face-to-face consultations, depending on each patient’s preference.

The MHOT is known as a First Contact Practitioner and can see patients with a range of presenting problems. They can also support with physical health conditions that may impact on an individual’s mental health or risks.

Almost 1,950 interventions were offered to patients during the year with appropriate support offered. The interventions can be split into three categories: self-management advice, signposting and referrals. The highest number of interventions offered were based around self-management tools and strategies, ranging from basic discussions around mental health self-care to much more detailed discussion around the patient’s specific mental health.

We now have two Mental Health Practitioners who offer direct support within GP practices, jointly funded through Nottinghamshire Healthcare Trust (the local mental health trust).

This link has helped to develop the relationship with the Local Mental Health Team and the Mental Health OTs now have direct access to Nottinghamshire Healthcare Trust’s notes system RiO to help support joined up working.

We have had some flux in the First Contact Practitioners (FCPs) over this past year which saw a reduction in hours for several GP practices but successful recruitment for others.  The success of the FCP model lies in the first contact aspect of a specialist practitioner who can provide accurate timely diagnosis and onward referral into specialist teams or for further investigation as necessary. Once fully trained, they have an up-to-date knowledge of pathways into secondary care including the spinal team.

Our Health and Wellbeing Coach supports patients with respiratory conditions, diabetes and prediabetes with one-to-one coaching. They also run two diabetic support groups, one in Kimberley and one in Beeston, together with the diabetic specialist nurse. They provide online diabetes and respiratory exercise classes and a face-to-face respiratory exercise class at Bramcote Leisure Centre.

We have four paramedics within in the PCN, one of whom works part time. They have all successfully completed the national Roadmap and one is being supported to deliver prescribing.

Over the past year, our Social Prescribing service has experienced numerous successes and various challenges. The team takes pride in being proactive within both healthcare and community/voluntary services. This approach enables them to anticipate needs, foster stronger community connections and provide more comprehensive support.

The service is delivered in weekly clinics from 12 GP practices within the PCN and the team has been able to educate surgery staff around what and who they are, encouraging and empowering staff including reception and admin to refer patients to the service.

Our Social Prescribers also form and maintain relationships with community and voluntary services and have attended multiple events including having stalls and speaking to audiences. These have included carers events, a children’s mental health day, and a 70 mile Samaritan walk.

Service developments this year have included:

• Under 18s: We opened a new service for under 18s in September 2023. We are the only social prescribing service in Nottinghamshire to have done this. We have supported a child as young as six years old.
• Self-referrals: We delivered self-referral roadshows across our three neighbourhoods in Stapleford, Eastwood and Beeston.
• Groups: We have set up six new community groups across the three neighbourhoods:
• Learning: Four team members are beginning their Level 3 social prescribing qualification and will be qualified by February 2025.

2023-24 saw the cardiology team move to taking referrals for patients who were potentially newly-diagnosed with hypertension. Numbers have gradually increased from 67 referrals, plateauing at approximately 130 referrals per month.

The hypertension diagnosis rate remains at the higher level achieved after the first hypertension case finding work in 2022-23. More information can be found in Appendix 3 – focus on health inequalities.

The team expanded with an extra pharmacy technician and non-prescribing pharmacists. This brought challenges for the existing team to train new members of staff simultaneously. However, it also brought capacity and therefore the opportunity to develop further and support practices to achieve the new cholesterol QOF targets.

The clinical pharmacy team has welcomed two new pharmacists and a pharmacy technician.

The team and GP practices have supported three clinical pharmacists and one pharmacy technician to successfully complete their CPPE pathway this year.

During 2023-24 we had two pharmacists and one pharmacy technician part-way through their CPPE pathway. The team has supported one pharmacist to achieve their prescribing qualification, giving us a total of 10 of our pharmacists able to prescribe.

This PCN funded team is crucial in supporting the Enhanced Healthcare in Care Homes (EHCH) framework. They ensure care homes receive weekly ward rounds and that patients undergo an eCGA within 7 days of admission and actively facilitate the completion of annual care plans. They consistently meet their KPI requirements. By the end of the financial year 2023-24, the team had achieved remarkable outcomes: 98.9% of patients have a care plan, 99.8% have undergone fall risk assessments, 96% of those on Gold Standards Framework (GSF) have Respect forms, and they’ve conducted dementia reviews, alongside supporting care homes in recognising malnutrition and SMRs through collaboration with the PCN’s pharmacy teams.

Given the often-challenging dynamics in care home environments, it’s evident that the team has effectively utilised their specialised expertise and interpersonal skills to strengthen relationships with staff and enhance their overall care and knowledge. A Consultant Geriatrician fed back: “I really enjoy the MDTs and feel part of the team. The visits that are generated following the MDT are always appropriate. I think the whole team contributes to better patient care in a cohort that were often just forgotten about.”

Our Specialist Cardiac Nurses support a complex caseload of patients requiring titration and optimisation of their heart failure medication in line with the four pillars of heart failure treatment and NICE guidelines. There has been a notable increase in demand for the service over the past 12 months, yet the team continues to provide safe and effective care for the patients. They have reported avoiding approximately 2,500 GP contacts and supporting admission avoidance for a further 2,400 contacts, whilst promoting referral to other services such as heart failure rehab, completing ReSPECT forms (a summary of recommendations for a person’s clinical care in a future emergency when they cannot make choices) and ensuring patients have a safety management plan (SMP) in place. The team also has access to the heart failure multi-disciplinary team with consultants and access to a day case unit for IV diuretics and iron infusions.

Our Respiratory Nurse Specialists offer support to patients with respiratory conditions such as COPD, Asthma, Bronchiectasis, and interstitial lung disease (ILD). Their support includes comprehensive specialist respiratory interventions. They have made nearly 3,300 patient contacts across the PCN area, reporting avoiding 285 admissions. Additionally, they provide a 48-hour telephone follow-up post-discharge, supporting the ongoing management of complex patients and assisting patients in their transition to our Non-Malignant End of Life Service. The team continues to provide home visits with a Respiratory Consultant to further enhance the support in the area and have provided safe and effective care managing risk with Home Oxygen patients. Remarkably, they are the sole team in the county actively involved in the recovery of adult spirometry in primary care. Furthermore, they have initiated a project aimed at enhancing the diagnosis of childhood asthma.

Our Pulmonary Rehabilitation team includes a Specialist Physiotherapist, Exercise Physiologist and Respiratory Nurse Specialist. The team provides evidence-based Pulmonary Rehabilitation in two venues in Nottingham West, supporting improved quality of life, reducing the risk of deterioration and admission. Over the past 12 months this service has had one of the highest completion rates in the county of approximately 80%, with 76% of patients demonstrating improvements in their walk exercise test. During the sessions, the patients receive targeted education and further self management advice.

The Diabetes Team has supported practices with the Diabetes local enhanced service. They currently deliver 26 sessions across practices in the area offering approximately 1,600 clinic slots through the year, alongside teleclinics and remote support for other health care professionals. They also support the running and development of diabetes support groups and provide training for primary care nurses. The team continues to be a source of support for other community colleagues and along with the other DSN, they provide essential guidance on the development of diabetes care across the integrated care system development of diabetes care.

Our Specialist End of Life Nurses assist patients who are in their final 12 months of life. Their role involves aiding other long term condition services and community providers in ensuring patients can live and die with optimal comfort. Notably, this team is unique in Nottinghamshire for focusing on non-malignant end-of-life cases. They specialise in pain management, psychological support, and palliative care, collaborating closely with other providers like hospices.