Case Study

Care provided by a connected, skilled and respected workforce

Work underway at Valens PCN in Northumberland that supports pillar five of the vision for primary care.
Victoria MacConnachie

4 October 2023

Valens PCN, Northumberland


In 2022, Valens PCN conducted a comprehensive internal stocktake of their current progress against the Fuller stocktake’s core vision and created a road map for its journey to progress further. The report focused on growing MDTs, improving access, and working with the new leadership team to find new opportunities to innovate and transform.

Workforce has always been a priority, and the PCN has recruited heavily into ARRS roles and dedicated time to developing MDTs and partnerships with organisations which support their ARRS staff, including Mental Health Concern; Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust (CNTW); and Northumbria Healthcare Foundation Trust. The PCN team has also focused on leading integration with local community teams, supported by the trust through alignment of the district nursing team under the leadership of a PCN neighbourhood matron. Further alignment has taken place within adult social care services, with designated care management enabling relationships to be developed that otherwise would have been fragmented.

Working with key partners in adult social care, mental health and in the community has enabled Valens to collaborate on the delivery of new multidisciplinary models of care. For example, a daily frailty MDT has been in operation since late 2020 to provide a proactive approach to managing the care of elderly patients and reducing hospital readmission. In this model, care is retained in the community or transferred from secondary to community-based care within a structured framework and supported by robust pathways. This structure allows the team to feel connected and supported to flourish, leading to true integrated, collaborative working as well as supporting future workforce development by utilising PCN additional roles such as social prescribing for maximum benefit.

Developing on this success, Valens has developed its mental health workforce in partnership with CNTW. This has led to the development of an adult mental health MDT service for complex mental health needs. This forum brings together key clinical, social prescribing and voluntary sector services that can assess patient needs and agree appropriate next steps.

Each MDT combines staff from across the PCN and relevant partners, and enables staff to take a more proactive, personalised approach to managing complex needs. Patients benefit from the collaborative approach as expertise can be shared and support can be coordinated across teams, including community partners. Adopting the MDT approach has also benefitted the PCN by improving communication and building relationships, driving greater efficiency and productivity, reducing isolated working and stress, and increasing job satisfaction among staff working on MDTs. The MDTs have also reduced the number of repeat GP appointments for patients with complex needs and duplication.

Moreover, the growing teams are becoming increasingly integrated with their wider system partners and provide the foundation of a full integrated neighbourhood teams approach. As part of developing the current model towards a single integrated team, Valens plans to continue to develop relationships with the voluntary sector and take advantage of key specialisms in mental health and wellbeing. The PCN wants to offer more outreach, working in community settings, and has appointed a health and wellbeing coach who will work alongside the mental health and social prescribing teams.