A Cheltenham Primary Care Network (PCN) has scooped a top award for its joined up work to proactively care for a diverse range of patients across its population.

Judges at the Pulse General Practice Awards were impressed by Central Cheltenham PCN which won the PCN of the year category.

During the last four years the PCN has transformed from six individual practices working in relative isolation to a hub of collaborative working and innovative practice.

The 57,000 patients registered at the practices benefit from new additional services provided by 33 members of staff with a wide skill mix.

Clinical Director Dr Olesya Atkinson said: “Our workforce development has had a really positive impact on patient care in our area.

“We developed additional roles including a PCN lead nurse role to support the nurses across all the PCN practices, enable more peer networking, standardise clinical protocols and nurse training and bring specialist care into the community such as diagnostic respiratory service and multidisciplinary team (MDT) diabetes care.

“By using these different roles, our PCN has been proactive in its delivery of care to patients particularly those who are substance misusers, children and young people, and those who are nearing the end of life.

Other initiatives include a virtual whiteboard – a digital tool that helps identify patients nearing the end of their lives to uncover any outstanding care needs. And as well as setting up a first contact practitioner (FCP) musculoskeletal (MSK) service, which has been showcased by the Chartered Society of Physiotherapy, the PCN has also helped support a befriending scheme using community volunteers who receive robust training to provide one-to-one support for vulnerable and socially isolated adults.

One example of the PCN’s many success stories includes a ground-breaking population health management (PHM) project to support children and young people (CYP) at risk of future health and wellbeing problems, offering them bespoke help.

More than 50 children are now receiving tailored care to help prevent long-term mental health problems.

They are being proactively contacted by a social prescribing link worker employed to work specifically with children and young people and offered a six-week face-to-face course on mental health resilience, including personalised support with issues such as anxiety or educational difficulties.

The course also includes topics such as the importance of going outside, appropriate relationships, having fun, healthy eating, managing emotions, friends and family. For parents this can help with parenting skills, routines and boundaries.

Annie Anderton is a CYP prescriber at the PCN who works for Caring for Communities and People, a voluntary sector organisation working with the PCN to deliver the scheme as part of a joined up approach.

She said: ‘The children being offered this programme are not known to other services so we’re supporting a group who otherwise might not have received any help.

“This is advanced proactive care and we’re excited to be able to identify and help so many young people and positively influence their lives.