We have collated all the projects and completed project outcomes from the three cohorts of our mid-career fellowship.
Phoenix-PCN Mid Career Fellowship Projects: 2024
Fellowship 1: Working with the vaccine coordinator, to focus on improving childhood vaccine uptake in the PCN patient population, particularly by addressing local health inequalities, understanding barriers for engagement and facilitating education to parents by addressing any misinformation.
Fellowship 2: To improve the metabolic health of people with pre-diabetes and diabetes by addressing root causes of diet and lifestyle “to educate not medicate” and implement changes through building on the education programme developed during 2022-23.
Fellowship 3: To improve breast, cervical and bowel cancer screening within the PCN. Understand our barriers locally to screening uptake.
Fellowship 4: Lifestyle medicine project: Pilot diabetes group consultations in CMC and disseminate across PCN and dsseminate lifestyle medicine methods & techniques to enhance patient care across PCN
Fellowship 5: To recognise the importance of recognising diabetes early but importantly give patients the tools to improve their sugars and prevent progression onto diabetes. Aim is to standardise care and support available within the PCN.
Fellowship 6: Review the current landscape of contraception, particularly LARC prescribing, and capture a clear indication as to why LARC is not chosen for the majority of women of reproductive age. Educate and signpost patients on LARCs, aiming to increase uptake.
Fellowship 7:CVD prevention and diagnosis. PCN identified need: to appoint a clinical lead, drive the objectives of the CVD prevention and diagnosis DES and implement priority QI projects in line with this.
Fellowship 8: To undertake the necessary training to fit LARCs and co-ordinate with other practices within the PCN, who currently provide this service, to offer a joint PCNLARC fitting service. Then evaluate the project and make recommendations for improvements and produce a template for other PCNs to introduce their own LARC service.
Fellowship 9: To become proficient in coils and implants and set up a LARC clinic in the PCN
Fellowship 10: Menopause care: Develop a toolkit for clinicians regarding patient information; Consider implementing group consultations; Standardise HRT prescribing- make it safe for patients and easier for practices; Explore impact of menopause and offer support for the PCN workforce.
Fellowship 11: To evaluate if there are inequalities in menopause care throughout primary care, what barriers there might be and implementing training and resources to improve this.
Fellowship 12: To help design, pilot and implement a practical diagnosis pathway for asthma in children and young people.
Fellowship 13: Targeted lung health checks
Fellowship 14: To streamline pathlinks process & find efficiencies within it to save time for clinicians & admin staff. Design new protocol for allocating GPs to receive results, & review/redesign the process for when results come back into the surgery. Look at current use of technology.
Fellowship 15: To explore deeper links between the providers of education and may allow opportunities to deepen links with children’s social services. Mental health support teams (MHSTs) are a relatively new initiative in schools which are being rolled out nationally, for example. Use a qualitative approach to engage in conversations with local education providers and explore the structures from grassroots through to Department of Education (DoE).
Fellowship 16: To improve patient engagement to better reflect the views of all patients. To establish a patient advisory group that better represents the patient populations in our PCN. Also to look at establishing better links with research, to increase our PCN populations involvement and participation in research.
Fellowship 17: Analysis of practice appointment and telephony data allowing improvement in capacity and access provision across the PCN. Scrutiny of rota design and appointment mapping data and ways of working to improve access and capacity within the PCN.
Fellowship 18: Improve communication between care homes and GP surgeries. Overall aim is to improve patient care and decrease urgent care/reactive demands on General Practice.
Fellowship 19: Identify and improve health inequalities across the PCN, likely focusing on CVD or diabetes. Review how existing and new digital/online communication tools can be used to achieve better outcomes, in line with the increasing emphasis placed on digital access and communication in the NHS Digital Pathways Framework
Fellowship 20: Explore barriers to patients with health inequalities (particularly SMI and LD) to accessing healthcare. Explore ways to engage more effectively with these groups to improve outcomes.
Fellowship 21: Design and implementation of SMD practice toolkit/SMD portal/SMD education and raising awareness
Phoenix-PCN Mid Career Fellowship Projects-Outcomes: 2022-23
Fellowship 1: Improving metabolic health in patients with DM and pre-DM by group support and educational sessions: three cohorts completed. Improvements demonstrated in BP/weight/girth /HbA1C/lipids.
Fellowship 2: Exploring factors for cancer screening in non-engagers. Educating ARRS colleagues in less common/poor prognosis cancers – resulting in one new pancreatic cancer diagnosis already.
Fellowship 3: Roll out of new menopause clinic and examination of referral patterns particularly in BAME ladies. Delivery of menopause education to Hindi speaking patients via local radio station. Abstract submission to BMS.
Fellowship 4: Standardising care for non-care home housebound patients using multidisciplinary team approach.
Fellowship 5: Exploring barriers to uptake of LARC in local BAME populations; production of LARC patient information leaflets in three commonly spoken languages in the locality.
Fellowship 6: Exploring patient reasons for non uptake/completion of NDPP; membership of population health management group and provision of healthy lifestyle/diabetes support.
Fellowship 7: Review of mental health care in student populations.
Fellowship 8: Introduction of group consultations in menopause care.
Fellowship 9: Frailty – improving read coding within practices; upskilling in frailty work; Fellow undertaking diploma in geriatric medicine. Producing a leaflet “top tips for staying healthy in later life”.
Fellowship 10: Improving outcomes in patients with mild frailty through provision of exercise and education. Team approach working alongside ABL provider.
Fellowship 11: Dissemination of “green” asthma learning across the ICS and educational institutions; educating children and young people re risks of air pollution.
Fellowship 12: Achievement of practice training status and introducing training. Standardise support and training of ARRS roles.
Fellowship 13: Develop a MSK/FCP roadmap and integrate FCP into practices. Explore understanding of FCP role in varied primary care staff/patients and FCP to inform future support and development of the service.
Fellowship 14: Explore recruitment and retention of GPs in deep end areas including barriers to working in such areas. Questionnaire to first 5 GPs and GP Registrars in Nottingham and Midlands regions – >90 responses with qualitative analysis. Aim to publish in a journal and produce recommendations for local area.
Fellowship 15: Recruitment and embedding of 4-5 new social prescriber role in practices. Evaluating staff understanding of the role and provision of education.
Fellowship 16: Provision of virtual yoga sessions to primary care staff.
Fellowship 17: Review of process for undertaking medication reviews.
Fellowship 18: Exploring barriers and enablers to introducing projects using artificial intelligence in primary care.
Fellowship 19: New SystmOne protocol devised to identify/flag up bloods required for drug and condition monitoring. Outstanding bloods added to clinician’s request. System allows patients to book blood test directly, avoiding reception. Adopted by 9/12 practices in PCN. Similar system based on this also now adopted using dot visualisation in two other PCNs.
Fellowship 20: Evaluation of a NHSE/community engagement child vaccination uptake project.
Phoenix-PCN Mid Career Fellowship Projects-Outcomes: 2021-22
Fellowship 1: Looking at perceptions in obesity to help shape Guthrie weight management services. Qualitative study with patient interviews and subsequent generation of recommendations to promote changes/for service provision.
Fellowship 2: Healthy weight project for adults. Supported practices to each identify a weight management lead practitioner; delivered education on obesity coding/registers and referral pathways; advised practices how to claim payments for obesity referrals; facilitated/supported social prescribers to engage patients to work on weight management; produced recommendations for clinicians to use to approach patients with obesity. GP fellow was successful in being recruited to the GLOW (GP Leadership in Obesity and weight management) course, which enhanced knowledge and understanding of obesity as a long term chronic condition and provided an opportunity for leadership skills training.
Fellowship 3: To better understand the role of a mental health practitioner in primary care and support and mentor the new mental health practitioner (MHP) role within the PCN. To support and develop the Health Improvement Worker (new role) to undertake physical health checks in patients with mental health diagnoses. To improve communications with secondary care services and gain agreement on lines of support/education for mental health practitioners.
Fellowship 4: Study of childhood immunisation uptake in identified groups. Review of ethnicity/language of children not brought for vaccinations; Collaboration with community focus groups to raise awareness/educate parents; Create child health information leaflets in various languages to support parents in making positive choices regarding vaccinations and healthcare; Undertake literature review to explore the barriers to uptake of childhood vaccinations and make recommendations to increase uptake.
Fellowship 5: Understand current staff wellbeing in Nottingham GP practices; is there a need for improvement? Understand current occupational health arrangements for staff employed within Nottingham GP practices. Identify resources available to Nottingham primary care staff. How does this compare to other areas/CCGs? Use of People Pulse questionnaire to survey PCN staff.
Fellowship 6: Aim to address inequalities in screening uptake for bowel, breast, cervical cancer and AAA screening in patients with learning disabilities. Liaised with learning disability nursing team, screening hubs, and people with learning disability to find out their views and current practice. Created local protocol for improving screening uptake, read-coding and development of website which collates easy-read information and videos. Drop-in face-to-face screening awareness event held. Produced a fantastic website about screening targeted at patients with learning disabilities.
Fellowship 7: To identify and tackle health inequality priorities in the PCN. Use of breast cancer screening audit to make recommendations to improve screening uptake. Circulation of information and training of social prescribers and practice staff about DESMOND scheme with inclusion in PLT session. Explored issues relating to inequalities in child vaccination uptake and inequity of QOF vaccination payments paid to practices. Raised profile of this inequity with BMA; question and research submitted to LMC; written article on child immunisation QOF payments increasing health inequalities published in Pulse; became clinical lead for 2 years to work on improving childhood vaccination uptake.
Fellowship 8: Improve management of long term conditions, particularly T2DM. Research best practice for transition of care for young people from paediatric to adult services. Provide additional training, support and supervision of ARRS staff members to take on routine management of LTC. Optimise admin processes within practice for annual reviews/LTC management and standardise processes across PCN.
Fellowship 9: To understand current provision of health, education, social care services and map the pathway for children and young people with mental health symptoms; including those who do not reach thresholds for child and adolescent mental health services (CAMHS) and healthy families teams. To make meaningful links with stakeholders that could enhance their care, to link this up with regional data and include local authorities in the work. GP Fellow became PCN CD and undertook a MA course in philosophy/ethics.
Fellowship 10: Improve physical health in SMI patients. Employing health improvement worker to run physical health check clinics; addressing barriers to uptake. Development of an integrated care approach covering both physical and psychological health and engaging health and wellbeing coaches and practice pharmacists to support the process. Recommendations made for maintaining provision of such a service within the PCN and potentially further work to enable adoption throughout ICS.
Fellowship 11: Developing a programme to improve primary prevention of CVD/stroke in those with undetected hypertension/obesity. Explore services already on offer and liaise to find potential for project co-working. Establish roadshows in community to assess impact and numbers. Discuss other avenues for accessing public who do not attend health premises e.g. going to workplaces, BP testing in supermarkets. Consider impact on increased workload for hospital phlebotomy services and discuss ways round this. Assess and formulate how pharmacy hypertension services could be used within model. Formulate a model using the above to increase numbers of those accessing services and being treated for hypertension. Fellow joined ICBCVD steering group and hypertension task group.
Fellowship 12: Defined an approach for identifying and addressing the unmet needs of patients with poorly controlled type II diabetes (through semi structured qualitative patient interviews) who were in the most deprived 2 deciles. Recommendations made for addressing unmet needs including improving access to health & wellbeing coach; promotion of online self management tool; exploring offering blood glucose monitoring; setting up diabetes peer support groups facilitated by H&WB coach.
Fellowship 13: Set up a dermatology clinic within the PCN for the purpose of diagnosis and treatment of adult and children with non 2ww dermatology referrals. <5% of patients required onward referral; wait times only 1-3/52; positive feedback from patients and GPs within PCN. GP Fellow gained accreditation as GPwER in dermatology.
Fellowship 14: Explored breast, bowel and cervical cancer screening uptake in patients with learning disabilities.
Fellowship 15: To examine the local view of barriers to cervical smear uptake and to see what improvements could be made.
Fellowship 16: Investment and Impact Fund project on sustainable inhaler prescribing. APC guidance – changed, optimise RX; Teaching sessions to different cohorts on the subject; pcn nurses, pharmacists, meds opt, resp group ICS, you tube- different PCNs/PICS; Nottingham VTS. Produced and distributed a targeted disposal poster. Linked up with the local council, aligning campaigns on social media and other outlets. GP Fellow became part of the Green inhalers group at the ICB; made links with secondary care physicians; member on ICS respiratory group; participated in “we are notts” event; links with Rushcliffe Borough Council; RCGPVOT faculty Green lead; become a Global Action Plan clean air champion – national scheme with a focus on air pollution and improving awareness; LMC- green group; Greener practice group (national network that supports primary care in reducing its environmental impact)
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