Team Up approach provides freedom to innovate for PCNs

A forward-thinking integrated care programme in Derby and Derbyshire is creating the conditions in which primary care networks (PCNs) and local place alliances are able to introduce innovative new roles in the community.

Team Up Derbyshire is an ambitious programme seeking to establish one team across health and social care that sees all housebound patients in a neighbourhood.

Dr Ian Lawrence, clinical lead for Ageing Well and Team Up Derbyshire, said: “The thing I am most proud of with Team Up Derbyshire is that we have created the conditions for local teams to figure things out for themselves and to learn from each other. It hasn’t always been comfortable, but these innovations are testament to the power of this approach. We haven’t always got what we expected, but that is usually because a local team has come up with something better than we could have planned.”

The new roles being implemented by PCNs within Team Up include:

Getting on the front foot in providing proactive care – Arch PCN

Arch PCN (covering Alfreton, Ripley, Crich and Heanor) has appointed an elderly care liaison officer, Cheryl Stanley, to visit people in their own homes to take a more holistic assessment of an individual’s health and care needs. Cheryl, a former healthcare assistant, began her visits in May 2022 and is taking referrals from across the nine GP practices in the three neighbourhood areas, in an attempt to work with patients before they have a crisis.

Cheryl says: “GPs and nurses simply do not have the time sometimes to spend with people to listen and understand all of their health and wellbeing needs. I am in a privileged position to be able to sit down with someone in their own home and build up a rapport with them.”

Offering GPs a different way of working – Derby City PCNs and Chesterfield and Dronfield PCN

PCNs across Derby and Derbyshire, in areas such as Chesterfield and Derby, are promoting the opportunities and benefits of becoming a community GP. The innovative role provides the chance for GPs to develop flexible, portfolio careers working alongside their health and social care colleagues in multi-disciplinary teams in the community.

Dr Amy Lampard, a community GP with Chesterfield and Dronfield PCN, said: “This model of working allows the community GP and team members to take a more holistic view of the person they are caring for and allows for greater continuity of care. The care provided tends to be more joined up between disciplines, where you can really get to know the patient, and often by doing so, we can anticipate the individual’s care needs before any concerns escalate.”

A new video featuring community GPs in Derby and Derbyshire discussing the benefits of the role is now on YouTube:

Bringing new skills into primary care – Derbyshire Dales PCN

PCNs across Derby and Derbyshire are currently advancing their home visiting services – in Derbyshire Dales the service is being led by a community GP with the support of a number of different professional roles including paramedics. A comprehensive induction programme was prepared for the four paramedics joining the team to support their transition from the ambulance service to primary care.

Alex Guevara, operations lead for Team Up Derbyshire Dales, who has worked as a paramedic and clinical practitioner, says: “Paramedics are an obvious choice to play a key role as they are already very capable of providing a high standard of care to those in their own home. Our new service allows them to spend more time with patients in order to identify needs other than the more obvious medical care.”

Further information

• Helen Baxter, Deputy Ageing Well Programme Manager, [email protected]

• Team Up Derbyshire website: https://joinedupcarederbyshire... and Team Up Derbyshire blog: https://teamupderbyshire.wixsi...

  • Leadership and Management
  • Leadership and Management > Service Design/Innovation
  • Leadership and Management > Service Design/Innovation > Service pathway improvements
  • Primary Care
  • Primary Care > Care of the elderly services
  • Primary Care > Listening to service users
Download acrobat reader