Our Services

Our Services

Care Coordinators

Care Coordinators are part of a GP surgery’s multidisciplinary team, working alongside GP’s, social prescribing link workers (SPLWs), pharmacy staff, nurses, health and wellbeing coaches, surgery administrative staff etc. to provide and coordinate, an all-encompassing approach to personalised care and promoting and embedding the personalised care approach across the Primary Care Network.

Work with the frail/elderly and those with long term conditions to personalise care, supporting patients to understand and manage conditions, and

  • Help to ensure a patient’s changing needs are addressed
  • Provide coordination and navigation of care and support across health and care services e.g. hospitals, diabetes teams, falls teams, memory clinic etc.
  • Work with patients in both the community and care/nursing home setting
  • Bring together all the information about a person’s identified care and support needs, and explore options to meet these, within a single personalised care and support plan (PCSP) on SystmOne
  • Review patients’ needs and help them (or families) access the services and support they require to understand and manage their own health and wellbeing, referring to social prescribing link workers, health and wellbeing coaches, and other professionals where appropriate
  • Reduce frequent surgery attendance and hospital admissions
  • Potentially provide time, capacity and expertise to support people in preparing for or following-up clinical conversations they have with primary care professionals to enable them to be actively involved in managing their care and supported to make choices that are right for them
  • The aim of the CCO is to help people improve their quality of life.

Clinical Pharmacists

Clinical Pharmacists work as part of the general practice team to resolve day-to-day medicine issues and consult with and treat patients directly. This includes providing extra help to manage long-term conditions, advice for those on multiple medications and better access to health checks. The role is pivotal to improving the quality of care and ensuring patient safety.

Having a clinical pharmacist in GP practices means GPs can focus their skills where they are most needed, for example on diagnosing and treating patients with complex conditions. This helps GPs manage the demands on their time.

What can a Clinical Pharmacist do in General Practice?

Some of the skills that the Clinical Pharmacist would be able to demonstrate safely are:

  • Work with doctors and patients to address medicine adherence, reducing the wastage and overuse of medicines
  • Monitor patients’ blood results, focusing on potential harm that can come from long-term use of medicines or poor compliance
  • Review patients on complex medicine regimens/ with ongoing health problems
  • Support doctors by highlighting changes in NICE guidelines
  • Triage and manage common ailments
  • Take part in multi-disciplinary case reviews
  • Deal with medication for patients recently discharged from hospital, including liaison with hospital, community and primary care colleagues
  • Work with the practice team to deliver repeat prescription reviews, especially for care home residents, people prescribed polypharmacy and frail older people
  • Look at how best practice is integrated into care processes and improve the quality of patient care, ensuring patient safety
  • Manage and prescribe (if qualified) for long term condition patients

Community Matrons

Community matrons are highly experienced, senior nurses who work closely with patients (mainly those with a serious long term condition or complex range of conditions) in a community setting to directly provide, plan and organise their care.

As well as providing nursing care, community matrons act as ‘case manager’ – a single point of contact for care, support or advice, typically for a caseload of around 50 very high intensity users.

Community matrons are usually deemed to be working as advanced nurse practitioners – highly skilled nurses who can:

  • take a comprehensive patient history
  • carry out physical examinations
  • use their expert knowledge and clinical judgement to identify the potential diagnosis
  • refer patients for investigations
  • where appropriate make a final diagnosis
  • decide on and carry out treatment, including the prescribing medicines, or refer patients to an appropriate specialist
  • use their extensive practice experience to plan and provide skilled and competent care that meets patients’ health and social care needs, involving other members of the healthcare team as appropriate
  • ensure the provision of continuity of care, including follow-up visits
  • assess and evaluate, with patients, the effectiveness of the treatment and care provided and make changes as needed
  • work independently, although often as part of a healthcare team
  • provide leadership
  • make sure that each patient’s treatment and care is based on best practice.

Most posts tend to involve working with the complete age range, but some posts may be designated to work with specific client groups, such as the elderly or children. We are extremely lucky to have 2 experienced Community HCA’s supporting the Community Matron with the above tasks which means that we can help more people in the Community than a Matron alone.

Health & Wellbeing Coaching

Health and wellbeing coaches (HWBCs) will predominately use health coaching skills to support people to develop the knowledge, skills, and confidence to become active participants in their care so that they can reach their own health and wellbeing goals. They may also provide access to self-management education, peer support and social prescribing.

Health coaches will support people to self-identify existing issues and encourage proactive prevention of new and existing illnesses. This approach is based on using strong communication and negotiation skills and supports personal choice and positive risk taking.

They will work alongside people to coach and motivate them through multiple sessions, supporting them to identify their needs, set goals, and help them to implement their personalised health and care plan.

Social Prescribing

Social prescribing is a way for local agencies to refer people to a link worker. Link workers give people time, focusing on ‘what matters to me’ and taking a holistic approach to people’s health and wellbeing. They connect people to community groups and statutory services for practical and emotional support.

Link workers also support existing community groups to be accessible and sustainable, and help people to start new groups, working collaboratively with all local partners.

Social prescribing works for a wide range of people, including people:

  • with one or more long-term conditions
  • who need support with their mental health
  • who are lonely or isolated
  • who have complex social needs which affect their wellbeing.

When social prescribing works well, people can be easily referred to link workers from a wide range of local agencies, including general practice, pharmacies, multi-disciplinary teams, hospital discharge teams, allied health professionals, fire service, police, job centres, social care services, housing associations and voluntary, community and social enterprise (VCSE) organisations. Self-referral is also encouraged.

Social prescribing complements other approaches, such as active signposting.  This is a ‘light touch’ approach where existing staff in local agencies provide information to signpost people to services, using local knowledge and resource directories. Active signposting works best for people who are confident and skilled enough to find their own way to services after a brief intervention.