As Primary Care Networks (PCNs) continue to define their role, Nursing in Practice‘s sister publication, Healthcare Leader, is speaking to the professionals who are helping to shape them.
Kathryn Dalby-Welsh is a complex care nurse and clinical director of Yeovil PCN, handling both roles alongside one another: ‘I do three days a week with complex care/primary care, employed by one of the practices,’ she explains. ‘I have a complicated role – two days or a day and a half a week I work as clinical director, but it’s all kind of interlinked. It’s about integrated care so there’s a lot of symmetry between the roles.’
Formerly the lead of the Symphony Project, which connected Yeovil District Hospital with local primary care services, Ms Dalby-Welsh worked closely with general practices to support individuals with complex health needs. Through meetings called ‘huddles’, where various health professionals attended, including complex care GPs, nurses, key workers, the project team collaborated with practices frequently.
Via this connection, when the time came to construct a new PCN, Ms Dalby-Welsh was a strong candidate for clinical director. Caring for people with multiple long-term conditions, mental health issues and medication-related problems requires a balancing act, but strong communication skills are also vital for efficient integrated care.
‘In Somerset, we’re fortunate to have an excellent group of health coaches. We’ve got about 40. The huddles were timed for the GP practice and our team to think about how we could create plans for patients. Not necessarily physical plans but a way of working with these individuals that avoided them having to go into hospital and provided them with a good quality of life where they wanted to live,’ says Ms Dalby-Welsh.
‘Because I was already providing integrated care or working towards an integrated care system, a role that was sitting between primary care and acute care, they asked me to take on the role of clinical director.
‘What I can bring is my vision is for an integrated care system. I can see there are people with complex needs who spend time coming into the hospital and into the practice and there are other ways of caring for them. What is unique about me is that I have already had to network and make friends with lots of different [organisations] and build relationships with lots of different agencies. I don’t have to start at the beginning. We were already forming as a PCN.’
Collaboration, collaboration, collaboration
Working with community teams, district nurses, rehabilitation centres and physiotherapists, providing care for this specific population relies on collaboration – something that Ms Dalby-Walsh is encouraging. Through the Symphony Project, contacts and relationships were able to transfer over to the PCN, supporting the community in Yeovil, and allowing the process to naturally evolve.
‘We realised that the best work we did was when we were working more closely with the community teams,’ explains Ms Dalby-Welsh. ‘The PCN is still learning what it needs to do and where it sits and how it works, the community has always been there. Yeovil is an area of deprivation, it’s urban, it has people with learning disabilities, people with mental health [problems]. We really want to try and connect everyone to the right place and also because we’re quite a small community.’
Yeovil PCN serves a community of 58,000 whose care needs are constantly changing. While every PCN has a unique population, and it can attempt to tackle its problems independently, working within this strategy can be limiting. The main goal for PCNs, as set out by NHS England, is to enable greater provision of proactive, personalised, and coordinated care. This vision is shared by Ms Dalby-Welsh and other professionals like her who have proven to be successful in integrated care.
Being an established voice in the health community has also been useful. Forming relationships with other professionals as well as patients allows for better communication across practices, secondary and social care – and overall, better health outcomes.
Ms Dalby-Welsh says: ‘Everybody knows somebody who’s a high user, ie frequent attenders. They’re often the emergency department or often in the hospital. Because we have been working in silo, sometimes people are unable to make informed decisions about what’s best for them. By using shared treatments, escalation plans, by having shared conversations, by having a narrative, we’re able to then reduce duplication.’
Frequent communication has been vital. As more organisations become involved across health and social care, from local authorities to care homes and transportation services, Ms Dalby-Welsh emphasizes the importance of weekly meetings. Instead of monthly catch-ups, where several significant changes may have happened in the interim that are too large to cover in one session, weekly meetings allow big challenges to be met head-on in manageable loads – all with the aim of leaving a meeting with positive outcomes and proactive strategies.
Ms Dalby-Welsh summarises: ‘I think, just like many PCNs, we keep going with what we can do with the resources we’ve got. But I’m relentlessly optimistic.’