How this PCN blends traditional and digital care

River and Wolds PCN in Yorkshire is one of the 10 networks shortlisted for PCN of the year. This single-practice PCN exemplifies the potential in leveraging digital innovation, integrated workforce models and community partnerships. Dr Aroop Sen, managing partner and access lead, explains more.

At River and Wolds PCN, led by Ridings Medical Group in East Riding of Yorkshire, the case for change was driven by need. We recognised that transformation was essential to sustain services, support staff, and improve patient outcomes. The pandemic accelerated this, exposing health inequalities, digital exclusion, and fragmented care pathways. Data and patient feedback showed rising complexity in long-term conditions, access pressures, and workforce fatigue.

For example, patients had to call on the day to secure an appointment, often phoning back daily in the hope of booking a routine slot. On-the-day demand was overwhelming and never-ending; appointments would be gone by lunchtime, leaving no routine access. Patients described it as a lottery, while GPs faced escalating workloads and staff risked burnout.

As a single-practice PCN, our strength lies in our unified governance, which enabled us to respond quickly and cohesively to tackle the challenges. We adopted a two-pronged approach – building a robust digital system while also developing integrated multidisciplinary care to serve 50,000 patients across five sites.

We’ve shown how blending traditional continuity with modern primary care can deliver a patient-centred approach that provides exceptional access, outcomes, and satisfaction.

What we did

We pioneered an inclusive digital access system, now handling over 2,500 weekly patient contacts through Accurx triage, with hybrid options to ensure equitable access. Since we introduced this in October 2023, patients have experienced shorter wait times, improved continuity, and more proactive care.

Tools such as Accurx, including its home monitoring function, and education-led reviews have increased engagement and empowered self-management. We created Accurx pathways for home blood pressure monitoring to identify patients who are normal, those requiring further tests, or those who should be added to the hypertension register. A similar system is being developed for medication monitoring. Patients complete questionnaires instead of attending in person, with only those needing follow-up booked for a nurse call. Managed by non-clinical staff using clear pathways, this approach saves clinical time by reducing admin and unnecessary appointments.

Alongside digital innovation, we have embedded ARRS-funded roles, including physiotherapists, MSK specialists, a dedicated frailty/care home team, and care coordinators to deliver proactive care for vulnerable groups. A single digital care record, integrated with Accurx and remote monitoring, enables real-time collaboration between clinicians and external providers. For example, our care home team works with social prescribers and district nurses to hold regular multidisciplinary team meetings, reducing emergency admissions and coordinating anticipatory care planning.

Respiratory

Our respiratory model shows how digital care and integrated working can be combined.

High rates of unplanned asthma attendances prompted us to develop a comprehensive, data-led asthma review programme. We collaborated with Hull University Teaching Hospitals NHS Trust to streamline access to diagnostics, including FeNO testing.

Patients who once required secondary care referrals now receive specialist reviews, education resources, and personalised action plans within primary care. Working with Accurx, we aligned messaging on SABA overuse and inhaler technique, while also sharing digital asthma templates and pathways with neighbouring PCNs.

The result has been timely, holistic care, fewer unnecessary referrals, and greater autonomy for patients through supported self-management.

Community

We have also worked with partners to co-design solutions addressing both clinical and social determinants of health.

For example, we have developed several initiatives with East Riding Council and Humber and North Yorkshire ICB. These include health promotion campaigns, Living Well sessions, and targeted weight management programmes. This prevention work aims to address the social determinants of health - such as isolation, inactivity, and poor nutrition – and therefore reduce long-term demand.

Our social prescribing team work closely with community-based mental health groups such as Andy’s Man Club, offering peer-led support for men struggling with mental health issues. This collaboration alone has improved male engagement with services and reduced reliance on GP appointments.

We have also developed a new community cafe, which has become a valued local space for social connection and informal support. And we organised an event at the local library, bringing together over 30 community groups for celebration and networking.

Outcomes

Our digital triage system has shown it can manage significant demand. Over the last year, there were 3,779 requests per 1,000 patients - far above the national average of 736 and regional average of 485. In January 2025 alone, we received 10,206 patient requests and, in the past year, a total of 180,995.

The proactive respiratory work has also been a success. Unplanned asthma care fell by 9% compared with 140 PCNs in the IMP²ART programme (December 2023–24). This reflects the impact of digital triage, proactive reviews, education, and improved communication, which have reduced SABA prescribing across the PCN.   

This outcome reflects the impact of digital triage, proactive reviews, patient education, and better communication, which have reduced SABA prescribing across the PCN. Patients are now better supported with maintenance therapy and inhaler technique, leading to improved asthma control.

At system level, we’ve improved prescribing safety and supported the ICB with scalable service models. We’ve shared our workflows and innovations with neighbouring PCNs, helping inform new locally enhanced services.

Staff wellbeing has also improved through mentoring, protected learning time, and initiatives such as running clubs and peer support.

Future

We’re committed to developing the workforce of the future. We are proud to be a multiprofessional training site for GPs, advanced nurse practitioners, physician assistants, and nurses, aligned with Hull York Medical School and active in regional QI initiatives. We have built a compassionate, forward-thinking culture with a sustainable workforce model increasingly replicated across the region.

For us, integration is not about organisational mergers but about aligned goals, shared digital systems, and trust-based partnerships with secondary care, local authorities, and voluntary groups. This approach benefits patients with timely, holistic care and supports staff who report improved morale and higher levels of job satisfaction.

Our experience shows that meaningful integration starts with understanding local needs, building strong relationships, and staying focused on shared outcomes.

This is one of 10 PCNs shortlisted for PCN of the Year at the General Practice Awards. The winners will be revealed at the awards ceremony on Friday 5 December at the Novotel London West. If you’d like to be there on the night you can find out more here and book tickets here.