With the NHS long-term plan committing improvements to NHS support for all care home residents over the next five years, Primary Care Networks (PCNs) across Northamptonshire have a key role to play.

Our county’s PCNs, collaborative networks of local GP practices, are forming stronger links with care homes, partnering with nursing and residential care homes in their areas to provide services that benefit their residents.

The work supports health and wellbeing, enables residents to remain active community members and reduces unnecessary hospital admissions through anticipatory care planning. Care co-ordinators are central to this ambition, forging alliances and improving continuity of care by acting as a point of contact for residents, families and professionals visiting care homes, such as GPs and in-reach specialists. A shared and co-ordinated approach to delivery ensures residents have access to the best care possible.

Across Northamptonshire Rural, East Northants and Wellingborough PCNs, for example, nine care co-ordinators have been appointed, building positive relationships between GP practices and nursing and residential care homes in their communities. Led by an integrated occupational therapist, their work is critical to developing enhanced local primary care support.

Team structure reduces duplication and improves integration between NHS and social care providers. The approach also offers people living in residential settings the same level of holistic care as those in their own homes, enabling people to live and age well. Care co-ordinators work with individuals to develop personalised care plans that are accessible to GPs and other health care professionals. These provide a detailed picture of the person’s preferences, goals and wishes.

Meanwhile, the Red Kite Healthcare PCN, which covers four GP practices in Corby, Kettering and neighbouring communities, is developing a trio of measures to support its partner care homes. First, with care homes in the area housing residents from several GP practices, a dedicated telephone line for staff provides direct links to a central care co-ordinator (CCC). The ability to bypass GP reception phonelines not only saves care home staff time, but it also helps form positive relationships between care co-ordinators and care homes, facilitating a mutual understanding of patients’ needs that improves standards of care. The option to record a message for the CCC also proves more time efficient.

The second step being implemented by the PCN involves proactively calling care homes to update patients’ care plans. Such an approach seeks to foresee changing care requirements and reduce emergency calls. Thirdly, plans are in place to mirror this anticipatory approach for housebound patients, through which the PCN is excited to continue building positive relationships among the community.

In Northampton, the ARC Hub PCN, covering southern and eastern sections of the town, has implemented procedures to ensure key patient information is always visible to urgent care response partners, such as East Midlands Ambulance Service. Principally, personalised care and support plans (PCSPs) are an integral part of patient records on clinical computer system, SystmOne. This technology centralises health records in an electronic format, enabling push-of-a-button updates that ensure patients always receive the most appropriate care.

While the approaches Northamptonshire’s PCNs take may vary, each area is fully committed to advocating for patients and bringing agencies together – all in the name of providing higher standards of care and avoiding unnecessary hospital admissions.

“Influence and improve outcomes” – what the care co-ordinators say

“I enjoy being a care co-ordinator because I meet lots of interesting residents and care home staff.

“It’s good to be part of a team and working together on new ways to support residents to access services and get better quality of care.”

Linsey DeCaro, Primary Care Network Care Co-ordinator, Wellingborough

“I like being a care co-ordinator because I enjoy building new relationships with different services across NHFT and the community.

“To ensure those we support receive a high standard of care and support to prevent unnecessary hospital admission by anticipating change and collaborative working.”

Megg Sharman, Primary Care Network Care Co-ordinator, East Northamptonshire

“I really enjoy the personal relationships that are built with individuals living in nursing and residential care homes, as well as those living independently in the community.

“It’s particularly rewarding to locate and point individuals in need towards the appropriate care where otherwise they may have slipped through the system.”

Kellie Grindley, ARC Primary Care Network Care Co-ordinator

“I enjoy leading this project because I want to positively influence and improve outcomes for people living in residential settings.

“It is so important that they have the same access to meaningful activities as they would
in their own home.”

Amanda Meara, Primary Care Network Occupational Therapy Team Lead, Wellingborough