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Dene and Stour PCN multidisciplinary team

Why change was needed

For many patients, their GP’s surgery is their first port of call if they need non-urgent medical treatment. However, often a patient will have complex health needs that requires support from health professionals other than their GP. 
Before the introduction of multidisciplinary teams (MDTs), a GP would have to refer the patient to several other health professionals, which would mean multiple appointments in different locations and often patients were waiting longer to receive the care they needed.


What we did

Three new roles were created within Dene and Stour PCN: Health and Wellbeing Coach, Social Prescriber, and Care Coordinator. Each of these roles offer patients timely and convenient access to health and wellbeing support that is delivered from their GP surgery.

Once an assessment is made of a patient’s needs, they can be referred to see one or more of the new Wellbeing team who will then contact them by phone in the first instance to discuss their health needs and start to create a care plan.

The Wellbeing team will continue to support the patient on an ongoing basis, working together where appropriate, to help the patient improve their health and wellbeing.

The introduction of MDTs in Dene and Stour PCN has dramatically increased the scope of support that GP surgeries can offer to patients. The new Wellbeing team can support patients with issues such as housing, homelessness, addiction, bereavement, and debt, that would have previously required referrals to external services.

Patients are already enjoying the benefits of these new roles, including quicker, more flexible, and more holistic treatment that has been improved by the sharing of knowledge and skills between the MDTs. Furthermore, even if the patient does require a referral to an external service, the Wellbeing teams can offer vital support while the patient waits for their appointment.

The feedback from patients around the introduction of the MDTs has been overwhelmingly positive and there have been many positive outcomes because of the support the new roles have provided.


What’s next

Due to the success of the introduction of MDTs in Dene and Stour PCN, the CCG will look at how this model can be replicated in other PCNs across the system. The move towards an Integrated Care System makes it easier for PCNs to work together and share best practice that will improve the treatment patients receive.


Change in action

Patient X is an example of how the introduction of MDTs are benefitting the treatment that patients receive.

Patient X is a 59-year-old male who lives alone, has a history of mental health problems and is a frequent user of the GP practice. He was referred to the Wellbeing team for support with finance and housing issues, bereavement, and anxiety.

The Health and Wellbeing Coach and the Social Prescriber roles were identified as the roles that could meet the patient’s needs.

The Health and Wellbeing Coach offered tailored support to the patient who, when he was referred, was emotional, stressed, teary and defensive as well as being heavily overweight and having breathing problems. He was offered a range of support including breathing techniques and meditation to help with anxiety, bereavement support, nutritional and exercise advice. The Health and Wellbeing coach also offered an outlet for him to talk to.

The Social Prescriber assessed the specialist support that the patient needed and signposted him to professionals who were able to help. The patient received help with debt advice, housing support, a duty solicitor advised the patient of what action he needed to take, he was allocated a support worker and he was offered advice on what benefits to apply for in order to help him manage his finances.

The results were that the patient felt “more in control” after face-to-face appointments with the Wellbeing team and the advice he received “gave him direction”. The team reported that he looked a different man after just 2 weeks. He had made real progress and was calm, happy, his sense of humour had returned, and he had managed to let go of some of the pain he was holding onto. His demeanour was completely changed, and he was optimistic and excited about his future.