Structured Medications Reviews and Optimisation PCN members will support direct tackling of the over-medication of patients, including inappropriate use of antibiotics, withdrawing medicines no longer needed and support medicines optimisation more widely.
It will also focus on priority groups, including (but not limited to): asthma and COPD patients; the Stop Over Medication for People with learning disabilities or autism programme (STOMP); frail elderly; care home residents; and patients with complex needs, taking large numbers of different medications.
Enhanced Health in Care Homes PCN members will support implementation of the Vanguard models tested between 2014/15 and 2017/18. The aim of this service will be to enable all care homes to be supported by a consistent multi-disciplinary team of healthcare professionals, delivering proactive and reactive care. This team will be led by named GP and nurse practitioners, organised by PCNs.
Supporting Early Cancer Diagnosis The NHS Long Term Plan commits to delivering personalised care to all cancer patients by 2021, ensuring that every person with cancer has the best possible care and quality of life, and that system resources are utilised effectively. PCNs will have responsibility for doing their part, alongside the Cancer Alliances and other local partners, and this will be reflected in the service specification.
GP practices are likely to have a key role in helping ensure high and timely uptake of screening and case finding opportunities within their neighbourhoods.
PCNs will have a key role in helping to ensure that all their GPs are using the latest evidence-based guidance to identify people at risk of cancer; recognise cancer symptoms and patterns of presentation; and make appropriate and timely referrals for those with suspected cancer.
Alongside the service within the Network Contract DES, a QOF Quality Improvement module will be developed for national use in 2020/21 to help practices and PCNs understand their own data, and work through what they can do to achieve earlier diagnosis. This may require direct engagement with particular local groups of their community where there is the greatest opportunity for making a difference, as well as working with their local ICS to tackle diagnostic bottlenecks.
CVD Prevention and Diagnosis PCNs will have a critical role in improving prevention, diagnosis and management of cardiovascular disease. The Testbed Programme will test the most promising approaches to detecting undiagnosed patients, including through local pharmacies, as well as managing patients with high risk conditions who are on suboptimal treatment.
Tackling Neighbourhood Inequalities This service will be developed through the Testbed Programme. Through drawing on the existing evidence and programme, some of which is summarised in Chapter 2 of the NHS Long Term Plan and its annex on wider social goals, the testbed cluster will seek to work out what practical approaches have the greatest impact at the 30,000 to 50,000 neighbourhood level and can be implemented in PCNs. The specification will include good practice that can be adopted everywhere, tailored to reflect the specific context of PCN neighbourhoods.