Beckington Family Practice works in collaboration with 4 local practices to form Mendip Primary Care Network (PCN). Our PCN is made up of Beckington Family Practice, Park Medical Practice, Grove House Surgery, Mendip Country Practice and Oakhill Surgery. Together we employ a team of health care professionals to support our patient population.

Mendip Primary Care Network (PCN) is a collaboration between Beckington Family Practice, Mendip Country Practice, Grove House Surgery, Oakhill Surgery and Park Medical Practice who between them cover 38,115 registered patients. The PCN is not a legal entity but a collaboration between GP Surgeries that are working to provide proactive personalised, coordinated and more integrated health and social care for their community. PCN’s receive funding to expand the range and effectiveness of clinical and holistic patient centred service they offer.

How does this work in practice within Mendip PCN.

The Care Co-Ordination Hub is the best illustration of this within Mendip PCN. The Hub is a dedicated team of staff based in Shepton Mallet supporting our practices in their aim to provide personalised care to patients who need support. The Surgeries are however still the front line of Care and first point of contact for patients.

The Hub team consists of the following people:

• GP Complex Care Lead and GP Frailty Lead   8 Care Coordinators
• Complex Care Lead Nurse and Diabetes Lead nurse   2 Home visiting Paramedics
• Proactive Care Occupational Therapist and Proactive Care Nurse   5 Health Coaches & Connectors
• 3 Clinical Pharmacists and 2 Pharmacy Technicians

The Hub expands the level and type of care and holistic support services on offer to our patients by linking with other agencies like Adult Social Care, District Nurses, Occupational Health and Physiotherapy. This helps promote and improve ongoing patient care and health while reducing the direct demand on GP Practices, preventing unnecessary admission to hospital. This releases capacity within the Surgeries for day to day, urgent and acute care needs of the community.

There are various aspects to the support the Hub provides as described below :

Hospital discharge follow up:

Adult patients recently discharged from hospital will be contacted by a Care Coordinator within 72hrs of returning home identifying any areas where they need additional support. This could be help with personal care or help in the home, needing equipment to support mobility and safety at home or social and financial support. They may need help to arrange transport to hospital appointments or have questions about their medication. The Hub can signpost or refer to people who can help.

The Proactive Care Team

This is a dedicated team involved in proactive and preventative care of the Frail and Elderly in our community and Care Homes. They identify and assess vulnerable and “at risk” patients and provide clinical and practical support to improve health and promote safety in the home environment thereby avoiding repeat hospital admissions and enhancing the patient’s quality of life.

Cancer Support

The Care Co-ordination Team provide a Cancer Support Pathway for patients referred for investigations and can provide further support if a cancer diagnosis is received. This can be practical help organising transport, referral to other organisations for financial advice or counselling support, or support with medications.

Pre-Diabetes and Diabetes Support

The Hub supports patients who are pre diabetic (HbA1c 42-47) by offering referral to the Diabetes Prevention Programme to inform and support those wishing to remain healthy and prevent progression to a Diabetes diagnosis. The Hub also runs new initiatives and support groups for those with Diabetes who are seeking to achieve remission of their condition through education, understanding and action. These groups are evolving and have proved highly successful and well attended so far. This work is also supported by the Health Connections Team who run various exercise and wellbeing groups.

The Pharmacy Team        

In addition to supporting the Care Coordinators and the Proactive Care Team in their activities. The Pharmacy Team run other medication specific projects on behalf of the GP’s.  The Team manages post discharge medicines reconciliation, checks medication is prescribed safely, monitors the effectiveness of medications and carries out monitoring of high-risk drugs. Our Clinical pharmacists carry out Medication Reviews with patients and work as part of the wider multi-disciplinary clinical team at Mendip PCN.  The work of the Pharmacy Team frees time for more GP appointments and ensures safe and effective prescribing across our practices.

Health Connectors Team

The Health Connections team, the unsung heroes of Health and Wellbeing, work within the Care Coordination Hub.

They will accept referrals from Care Coordinators and GPs for holistic, practical and emotional help to support a patient’s health and wellbeing from trained health Coaches and importantly you can also self-refer into this service. You can see a Health Coach for one-to-one appointments, join one of their groups or find out about training and getting involved in your community. There is also a fantastic resource in the Online Directory for support and information in your area: Welcome to Health Connections Mendip - Health Connections

For more information and support in any of these areas you can contact The Care Co-ordination Hub on:

Tel: 01749 600379 Option 1

Email: somicb.mendipcomplexcarehub@nhs.net

The Beckington Family practice is using the “Brave AI” which helps staff to identify vulnerable patients who may otherwise go under the radar.

Following a successful pilot in care homes in Somerset which reduced resident falls by 35%, attendances to Emergency Departments by 60%, and
ambulance callouts by 8.7% the Brave AI device will be rolled out to over 30 areas in the South West in 2024.

By using a machine learning (AI) algorithm to look for patterns in registered patients’ records, the technology assesses an individual’s risk of unplanned
hospital admission in the next year.

Integrated neighbourhood teams of nurses, pharmacists, therapists, health coaches, social prescribers and doctors then use the information to reach
out to those in need.

They can then offer to put in place personalised support and create a personalised care and support plan. This may include other ways of working
setting up remote health monitors, offering apps to self-report wellbeing, or linking up with voluntary groups or classes to avoid loneliness.

To find out more about how the tool works and what this means for you please visit the NHS Somerset website here. If you would like to speak to
someone in person please speak to Charlie Stone or Abby Harrington on 01749 600379 who will be able to talk you through the device.