Case Study

Citizens as partners

Work underway at Stort Valley and Villages PCN to support pillar two of the vision for primary care.
Victoria MacConnachie

4 October 2023

Stort Valley and Villages PCN


Since 2020, Stort Valley and Villages PCN has been working to improve digital access and the outcomes for patients with long-term conditions. The PCN began working with their patient participation group (PPG) and the Patients’ Association to develop a strategy which would best meet patients’ needs and empower them to engage with their care on their own terms. The team has prioritised access, education, and patient experience so that patients feel that they are equal partners in their care and have the tools and knowledge to confidently make their own decisions about their health and wellbeing.

Let’s Talk Menopause

Both patients and GPs identified menopause support as a leading area for concern. The PCN team researched group consultations to address the issues of high demand, large amounts of GP time being invested in supporting patients with the same issues, and patients’ dissatisfaction with the outcome of ten-minute appointments, and launched a pilot for patients experiencing symptoms of menopause. The sessions were run online as virtual group consultations and were delivered by a range of practitioners as part of the menopause MDT, including a GP, an ARRS dietician, an ARRS health coach, and a secondary care gynaecologist. The group consultations provided patients with a support network and the knowledge they needed to manage their symptoms. This empowered patients to make more informed decisions on the best management for them, including  whether to incorporate HRT into their treatment. Those patients who opted for HRT following the group consultations were then offered 20-minute face-to-face appointments as part of a dedicated menopause clinic.

Patients who attended the group sessions were also connected to ongoing peer support through a WhatsApp group, run by the social prescribing team, and access to a gym. Social prescribers worked with the local sports development team to support ongoing self-management and the first pilot tried a £10 ‘prescription’ for six weeks’ access to the gym, and the second pilot offered £30 for three months’ access to a personal trainer funded by NHS Charities. 55 per cent of patients have taken this up and are still experiencing positive results.

Stort Valley and Villages PCN has run tranches tranches of the programme up to July 2023 and will continue to offer the service based on the positive feedback received from patients and staff. Patients have reported improvements in their symptoms, improved social connection and peer support, and improved experience of interacting with general practice. By working with the PPG to identify patient need and to codesign services which met that need, the PCN team has ensured that patients are treated as partners in their care and have the tools they need to manage their health and wellbeing. GPs have reported that their experience of working with patients has improved because the patients have a better understanding of their needs and the options available to them. Plans are in place to begin expanding this approach to other long-term conditions like diabetes and dementia.

Digital access in rural areas

Stort Valley PCN covers a rural area in which older patients are often less digitally aware and more likely to become isolated. The PCN, PPG, and Age UK have collaborated to improve patient access and understanding of digital tools. Through a number of programmes, the team has increased the number of patients who are confident using technology to access care and advice as well as information about services in their area.

The PCN team surveyed older residents and found that 33 per cent of the 290 respondents had no internet, and of those who did have internet, 39 per cent weren’t confident in how to use it. The PCN team then began working with volunteers, known as ‘digibuds’, to offer small group sessions on how to use smart phones and laptops to access the internet and contact family, look up information, and reach their GP practice. These digibuds provided a supportive learning atmosphere, keeping the groups small ensured that there was enough time to deliver a more personal and in-depth education. In addition to these drop-in sessions, Age UK now provides in-person support via a ‘digital health’ referral from the PCN team and helps patients in their own homes to get physically set up to access digital services. Once patients are online, they can access local connection hubs and see the PCN’s ‘shop window’ approach to displaying upcoming clinics, or opportunities to attend community events and programmes. This easy-to-view calendar aims to simplify access and improve the wider determinants of health, including social connection and financial advice, by making it easy for patients to identify relevant opportunities across primary and community care.

Every aspect of the digital inclusion work at Stort Valley and Villages PCN has been shaped by the PCN team, the PPG and system partners like Age UK. Their shared aim is to equip patients with the knowledge and confidence to navigate their local health and care system in order to put patients in control of as much of their care as possible.