Personalised care

Personalised care is one of the five major, practical changes to the NHS that will take place over the next five years, as set out in the NHS Long Term Plan. Personalised care means patients have control and choice when it comes to the way their care is planned and delivered, considering individual needs, preferences, and circumstances. There are currently three PCN multidisciplinary roles that deliver personalised care: care coordinators, heath and wellbeing coaches, and social prescribing link workers.

Useful links:

• NHS England: personalised care
• Personalised Care Institute

Care coordinators

Care coordinators are personalised care professionals who help to provide capacity, and expertise to support patients in preparing for or following up clinical conversations with clinical teams. They work closely with the GPs and other primary care professionals within the PCN to identify and manage a caseload of identified patients. Together they make sure that appropriate support is made available to the patient and their carers and ensure that their changing needs are addressed. Care coordinators focus on delivery of personalised care to reflect local PCN priorities, health inequalities or groups of patients identified through risk stratification. Care coordinators can also support PCNs in the delivery of enhanced health in care homes.

Useful links:

• NHS England: Care coordinators workforce development framework

Health and wellbeing coaches

Health and wellbeing coaches 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 and wellbeing coaches will support people to self-identify and manage existing issues. 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.

Useful links:

• NHS England: Health and wellbeing coaches workforce development framework

Social prescribing link workers

Social prescribing link workers help people focus on what matters to them as identified in their care and support plan. They connect people to community groups and agencies for practical and emotional support. Link workers typically work with people over six to 12 contacts (including phone calls and meetings) over a three-month period with a typical caseload of up to 250 people, depending on the complexity of people’s needs.

Useful links:

• NHS England: Social prescribing link workers reference guide for primary care networks

Clinical pharmacists work in primary care in a patient facing role to clinically assess and treat patients using their expert knowledge of medicines. They will be prescribers, or if not, are working to complete an independent prescribing qualification following completion of an approved 18-training pathway or equivalent. They work with and alongside the general practice team, taking responsibility for patients with chronic diseases and undertaking structured medication reviews to proactively manage people with complex polypharmacy, especially for the elderly, people in care homes and those with multiple comorbidities.

Useful links:

• Centre for Pharmacy Postgraduate Education: Primary care pharmacy education pathway
• NHS England: Clinical pharmacists

Pharmacy technicians complement the work of clinical pharmacists, through utilisation of their technical skillset. Their deployment within primary care settings allows the application of their acquired pharmaceutical knowledge in tasks such as medicines reconciliation, audits, prescription management support, and where appropriate, advising patients and other members of the PCN workforce.

Useful links:

• Health Education England: GP practice pharmacy technicians
• Association of Pharmacy Technicians UK and the Primary Care Pharmacy Association: National competency framework for primary care pharmacy technicians

First contact practitioner physiotherapists are qualified autonomous clinical practitioners who can assess, diagnose, treat, and manage musculoskeletal problems and undifferentiated conditions. Where appropriate, they are also able to discharge a person without a medical referral. First contact practitioner physiotherapists working in this role can be accessed directly by patients, or via referral from other members of staff. They can establish a rapid and accurate diagnosis and management plan to streamline pathways of care.

Find out more about first contact physiotherapists.

Occupational therapists support people of all ages with problems resulting from physical, mental, social, or developmental difficulties. Occupational therapists provide interventions that help people find ways to continue with everyday activities that are important to them. This could involve learning new ways to do things or making changes to their environment to make things easier. As patients’ needs are so varied, occupational therapists help GPs to support patients who are frail, with complex needs, live with chronic physical or mental health conditions, manage anxiety or depression, require advice to return or remain in work and need rehabilitation so they can continue with daily activities.

Useful links:

• Health Education England: Occupational therapists in primary care
• Royal College of Occupational Therapy: Occupational therapy in primary care

A paramedic in primary care can provide a rapid response to deteriorating patients and patients with long-term conditions, minor injuries, and minor illness. They can also support patients who require wound care, have fallen, have musculoskeletal problems, and have urinary tract or respiratory infections. Paramedics can supply a range of medicines through patient group directions, including antibiotics and analgesics.

Paramedics can support PCNs in responding to on the day demand by offering telephone triage or undertaking home visiting. They can also support PCNs to improve access to care by managing minor ailments and seeing patients in care homes.

Useful links:

• NHS England: Paramedics in general practice – scope of practice guidance
• Health Education England: Paramedic specialist in primary and urgent care core capabilities frameworks

Podiatrists have been trained to diagnose and treat foot and lower limb conditions. They provide assessment, evaluation, and foot care for a wide range of patients, which range from low risk to long-term acute conditions. Many patients fall into high-risk categories such as those with diabetes, rheumatism, cerebral palsy, peripheral arterial disease, and peripheral nerve damage.

Useful links:

• Health Education England: Podiatrists in primary care
• Royal College of Podiatrists: Podiatrists in primary care

Dietitians diagnose and treat diet and nutritional problems, both at an individual patient and wider public health level. Working in a variety of settings with patients of all ages, dietitians support changes to food intake to address diabetes, food allergies, coeliac disease, and metabolic diseases. Dietitians also translate public health and scientific research on food, health, and disease into practical guidance to enable people to make appropriate lifestyle and food choices.

Useful links:

• Health Education England: Dietitians in primary care
• British Dietetics Association: First contact dietitian

Advanced practitioners can be nurses, pharmacists, paramedics, physiotherapists, occupational therapists, dieticians, or podiatrists. They are educated to master’s level or equivalent, with the advanced skills and knowledge to allow them to expand their scope of practice to better meet the needs of the people they care for. Advanced practitioners work at a level of advanced practice that pulls together the four Health Education England advanced practice framework pillars of: clinical practice, leadership and management, education, and research. Using their advanced skillset and knowledge, they can manage undifferentiated cases and provide supervision across multiple professional groups.

• Health Education England: Allied health professions superpowers
• Health Education England: Allied health professions roadmap to practice
• NHS England: Allied health professions

Nursing associates deliver hands-on, person-centred care as part of the nursing team and support registered nurses to focus on the more complex clinical care. Nursing associate roles include performing and recording clinical observations (for example, blood pressure, temperature, respirations, and pulse), and performing clinical health checks.

Trainee nursing associates will develop the skills and knowledge, over the course of a two-year programme (for example, apprenticeship, foundation degree) to deliver high quality and compassionate care. They deliver specific clinical tasks and direct care to patients and families, under the direction of a registered nursing associate (or other registered care professional). Through their training they will develop an understanding of caring and supporting people with complex conditions such as dementia, mental health conditions, and learning disabilities. Trainee nursing associates upon completion of training can register as a nursing associate with The Nursing and Midwifery Council.

Both roles are included in the Primary care and general practice nursing career and core capabilities framework, which supports the development of nursing careers from support work to consultant levels of practice.

Mental health practitioners support adults whose needs cannot be met by local talking therapies, but who may not need ongoing care from secondary mental health services. The practitioner can be taken on by a wide range of clinical and non-clinical roles with mental health expertise (ranging from Band 4-8a), such as a community psychiatric nurse, clinical psychologist, mental health occupational therapist or a peer support worker.

Mental health practitioners for children and young people can be developed to meet a wide range of needs, from early identification and intervention in primary care, to more targeted or intensive support and interventions as part of a joined-up approach with children and young people’s community mental health services. The exact scope of the role and job description should be agreed between the PCN and the NHS trust but could include children wellbeing practitioners, community mental health nurse, and cognitive behavioural and family therapists.

As this is part of the wider transformation and expansion of community mental health services, the practitioner will be employed by the secondary mental health provider and will operate as a fully embedded member of the PCN multidisciplinary team. They will act as bridge between primary care and secondary mental health services and can facilitate onward referral to a range of services to meet patients’ needs.

Physician associates are healthcare professionals, with a generalist clinical education, who work alongside GPs to provide care as part of the multidisciplinary team. They provide care for the presenting patient from initial history taking and clinical assessment through to diagnosis, treatment, and evaluation. Whilst physician associates currently do not have prescribing rights prescribe, they can prepare prescriptions for GPs to sign. Apprentice physician associates undertaking approved training can be employed by PCNs under the Additional Roles Reimbursement Scheme from April 2023.

Physician associates:

• Demonstrate critical thinking in the clinical decision-making process, including assessment and diagnostic skills, leading to the delivery of safe care for all patients.
• Work collaboratively with the practice team to meet the needs of the patients, supporting the delivery of policy and procedures.
• Provide a holistic and clinical service, with support from GPs as required, implementing agreed management plans, and following approved protocols as appropriate.

General practice assistants deliver a combination of routine administrative tasks and some basic clinical duties in the general practice setting. Their focus is on supporting GPs in their day-to-day management of patients, specifically aimed at reducing the administrative burden and making best use of consultations. Administrative support includes letters, completing forms for GPs to sign, and explaining procedures to patients prior to appointments. Examples of clinical support include referrals, arranging follow up appointments, and conducting simple clinical observations.

Useful links:

• E-learning for health: General practice assistant national competency framework
• Health Education England: General practice assistants

Digital and transformation leads support increased access to care for patients, through the adoption of new technology and other initiatives to improve the care offer. This enables PCN staff to work more effectively and improves the sustainability of general practice services. Digital and transformation leads can:

• Develop strategic plans to optimise the use of clinical systems and build a robust digital infrastructure for PCNs working on a range of digital transformation projects such as the use of cloud telephony, digital triage, online signposting, social media, digital wayfinding, promotion of the NHS App.
• Deliver broader transformation projects to:
  • improve access to care and support the adoption of population health management
  • drive operational efficiency
  • enhance staff experience.

They support the adoption of national and local initiatives, including integrated working at neighbourhood and place level to improve access to services for patients.