Healthy Hyde PCN: Transforming Primary and Community Care for Integrated Services

HEALTHY 
HYDE 
PCN
FUTURE INTEGRATED CARE SYSTEMS – Getting Primary
and Community Care Reform Right
Agenda
Acknowledgement of Fuller Stocktake and King’s Fund Feb Report – thank you
Acknowledgement of my role here as an expert practitioner with a successful PCN
The 
Success Highlights 
– especially pertinent to questions 2 +8 (Population and their
voice) and 3 + 4 (Aims and Function) and 6 (our model)
Please see www.healthyhyde.com
The story of the evolution of Hyde PCN with emphasis on our Success Highlights
The structure of Healthy Hyde PCN
The successful investment of General Practice money in Estates
A small section on barriers
A re-evaluation of our Success Highlights
Conclusion and thanks to the Commission
 
The patient being placed at the centre of every interaction and decision from the start, with their
unique circumstances recognised
Utilising the strengths of the General Practice registered list – Personal, Powerful, Precious
Success Highlights
PCN 
Services to the Practices
8 GP Practices – from 4 000 to 18 000 list size covering around 75 000 population
Over 50 employees
New Body and Mind Centre in central shopping centre – FOCUS FOR INTEGRATED SERVICES
Covid
 
(and
 
flu)
 
vaccination
 
programmes
Paramedic run URGENT ACTION clinic for same day transactional needs and HOME VISIT support
MSK
 
acute
 
service
 
 
through
 
EMIS
 
Enterprise
Enhanced
 
Care in Care
 
Homes – with proactive care extended to the 
Housebound,
 
those
 who
are living at home with 
Dementia
,  those with Learning Disabilities and those with Severe Mental Illness
Extended
 
Access
 
evenings
 
and
 
weekends
Support
 
In
 
Practices – weekly (and emergency supply) of paramedics, pharmacists, HCAs,
receptionists, admin support
 
Tackling Health Inequalities
FOOD and HOUSING
 
SECURITY - Volunteering
 
at
 
four
 
food
 
banks
 
in
 
Hyde
 
area
 
-
 
building
relationships
 
and
 
trust,
 
offering
 
support
 
plans,
 
GP
 
and
 
mental
 
health outreach, warm hubs
LANGUAGE
 
SECURITY - 
ESOL
 
classes,
 
cooking
 
collaborations,
 
outward
 
bound
 
event. BAME
 
worker
delivering 
culturally
 
appropriate
 H
ealthy
 M
emory
 
support, 
walking
 
group
 
and
 
lunch
 
clubs with
health input e.g. cancer screening advice
COMBAT
 
LONELINESS - 
Healthy
 M
emory
 
café,
 
volunteer
s attending
 
community
 
and
 
faith
 
groups,
allotment
 
groups
STRUGGLING CHILDREN – 
Children’s School
 H
oliday
 C
lub,
 
mental
 
health
 
well-
being
 
activities
 
in
schools
The Place for Integration
Referrals from DWP, Housing, Social Services, Drug and Alcohol Team,
Midwives, Health Visitors, Sexual Health
Faith groups, Mental Health charities, cultural cook-ups
Care Leavers events
Liver Disease detection pilot involving fibroscanning
Barriers
The cost of reorganization and 
the resulting
 concentration of power, control and investment upstream
S
till
 being a startup; not embedded. This allows for innovation but also generates mistrust
Digital provision that is fit for purpose - new AI and digital are expected to solve all problems but prior
to this please ensure current digital offer works!
Future contracts and financial plans are only available days or hours before we are meant to
implement
Success Highlights
The patient being placed at the centre of every interaction and decision from the start, having
their unique circumstances recognised
Utilising the strengths of the General Practice registered list – Personal, Powerful, Precious
FULLY QUALIFIED GPs managing complex medical problems with a supportive MDT
Using above core principles to work for and with 8 very different practices
Using coalface experience to adapt to the needs of the community and to develop services
This may expose unmet need but is it the RIGHT THING and it will produce the community we all
want to live in
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"Explore the success and evolution of Healthy Hyde PCN in integrating primary and community care reform, with a focus on patient-centric services, innovative programs, and initiatives to tackle health inequalities. Discover the structure, services, and efforts to put the patient at the center of care delivery while addressing barriers in healthcare reorganization."


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  1. HEALTHY HYDE PCN FUTURE INTEGRATED CARE SYSTEMS Getting Primary and Community Care Reform Right

  2. Agenda Acknowledgement of Fuller Stocktake and King s Fund Feb Report thank you Acknowledgement of my role here as an expert practitioner with a successful PCN The Success Highlights especially pertinent to questions 2 +8 (Population and their voice) and 3 + 4 (Aims and Function) and 6 (our model) Please see www.healthyhyde.com The story of the evolution of Hyde PCN with emphasis on our Success Highlights The structure of Healthy Hyde PCN The successful investment of General Practice money in Estates A small section on barriers A re-evaluation of our Success Highlights Conclusion and thanks to the Commission Success Highlights The patient being placed at the centre of every interaction and decision from the start, with their unique circumstances recognised Utilising the strengths of the General Practice registered list Personal, Powerful, Precious

  3. PCN Services to the Practices 8 GP Practices from 4 000 to 18 000 list size covering around 75 000 population Over 50 employees New Body and Mind Centre in central shopping centre FOCUS FOR INTEGRATED SERVICES Covid (and flu) vaccination programmes Paramedic run URGENT ACTION clinic for same day transactional needs and HOME VISIT support MSK acute service through EMIS Enterprise Enhanced Care in Care Homes with proactive care extended to the Housebound, those who are living at home with Dementia, those with Learning Disabilities and those with Severe Mental Illness Extended Access evenings and weekends Support In Practices weekly (and emergency supply) of paramedics, pharmacists, HCAs, receptionists, admin support

  4. Tackling Health Inequalities FOOD and HOUSING SECURITY - Volunteering at four food banks in Hyde area - building relationships and trust, offering support plans, GP and mental health outreach, warm hubs LANGUAGE SECURITY - ESOL classes, cooking collaborations, outward bound event. BAME worker delivering culturally appropriate Healthy Memory support, walking group and lunch clubs with health input e.g. cancer screening advice COMBAT LONELINESS - Healthy Memory caf , volunteers attending community and faith groups, allotment groups STRUGGLING CHILDREN Children s School Holiday Club, mental health well-being activities in schools The Place for Integration Referrals from DWP, Housing, Social Services, Drug and Alcohol Team, Midwives, Health Visitors, Sexual Health Faith groups, Mental Health charities, cultural cook-ups Care Leavers events Liver Disease detection pilot involving fibroscanning

  5. Barriers The cost of reorganization and the resulting concentration of power, control and investment upstream Still being a startup; not embedded. This allows for innovation but also generates mistrust Digital provision that is fit for purpose - new AI and digital are expected to solve all problems but prior to this please ensure current digital offer works! Future contracts and financial plans are only available days or hours before we are meant to implement Success Highlights The patient being placed at the centre of every interaction and decision from the start, having their unique circumstances recognised Utilising the strengths of the General Practice registered list Personal, Powerful, Precious FULLY QUALIFIED GPs managing complex medical problems with a supportive MDT Using above core principles to work for and with 8 very different practices Using coalface experience to adapt to the needs of the community and to develop services This may expose unmet need but is it the RIGHT THING and it will produce the community we all want to live in

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