Kingswinford and Wordsley PCN in the West Midlands is one of the 10 networks shortlisted for PCN of the year. In response to the complex health issues facing the patient population, the PCN has adopted a model of care focused on prevention, inclusion, and proactive support. Clinical director, digital transformation manager, Dr Balraj Mavi, Radhwan Hoque, clinical pharmacists, Adam Malik and Sukhdeep Malhi and inequalities lead Rajvinder Mann explain more.

Our PCN of five practices serves a diverse population of more than 50,000 patients with varying health needs. We had always recognised that tackling long-term conditions and improving access to care couldn't be done in isolation and a rise in complex health issues made it clear that we needed to double down on this and think differently – to work together, not just within the PCN, but across the whole integrated care system.

So, over the past year, we’ve worked hard to move beyond traditional models of care, focusing on prevention, inclusion, and proactive support.

Aim

Like many areas, Kingswinford and Wordsley PCN has seen a rise in complex health issues, particularly obesity, poor mental health, substance misuse, and long-term conditions like diabetes and heart disease. Deprivation is also an issue, with around a quarter of children in our area living in low-income households.

In addition, some patient groups were not engaging with national screening programmes, and there were gaps in preventative care.

The need for change was clear.

We knew these challenges couldn’t be tackled alone. We aimed to strengthen existing relationships with other organisations - and build new ones where needed. By bringing everyone - secondary care teams, local voluntary groups, public health, and pharmaceutical partners – around the table, we wanted to find practical, joined-up solutions that would transform how we deliver care.

Approach

We started by looking at data - things like cancer screening uptake, diabetes outcomes, and gaps in diagnosis. 

One outcome was a new focus on kidney health. We carried out a full Kidney Failure Risk Equation (KFRE) review of our patient population in Wordsley - the first of its kind locally. This proactive audit identified high-risk patients, enabling early intervention to reduce the likelihood of renal failure and avoid dialysis through timely optimisation and referrals.

We also piloted a multidisciplinary team (MDT) approach for chronic kidney disease (CKD). Rather than casting a wide net, we selected the patients most likely to benefit – those on the CKD register with urine albumin-to-creatinine ratio (ACR) ≥10 and BMI ≥27. We started with one practice and an initial cohort of 21 patients to ensure the MDT was clinically impactful and manageable, with plans to scale following the pilot.

Just as valuable as data were the conversations with patients, community leaders and practice staff. These revealed real-world barriers - from language and transport to a lack of confidence in navigating healthcare. This helped us identify gaps in services, understand patient concerns and build trust with the people we serve.

To make meaningful change, we built strong partnerships with a wide range of organisations, including hospital consultants, the West Midlands Cancer Alliance, public health teams, and voluntary sector groups. We even worked with energy advisors to tackle wider determinants of health. And we collaborated with pharmaceutical partners on lipid management and cardiovascular disease (CVD) prevention projects. These partnerships supported safe medicine optimisation and better outcomes.

This integrated approach allowed us to deliver more joined-up support - for example, organising a wellbeing fair in September 2024 where patients could access multiple services in one place. It also strengthened our internal relationships, with shared projects such as AF detection kits and proactive diabetes reviews rolled out across all practices.

We’ve also taken steps to tackle health inequalities among specific groups, such as focused outreach to our migrant community using interpreters and translated materials.

Outcomes

Our wellbeing fair at Wordsley Community Centre brought together over 500 patients and 23 partner organisations for health checks, education, and on-the-spot support. It gave patients direct access to a range of experts from organisations such as Macmillan, Prostate Cancer UK, Your Health Dudley, Act on Energy, and local cancer screening programmes - all in one place. Feedback was overwhelmingly positive, with many patients saying they accessed services they didn’t know existed or felt more confident about taking the next step in managing their health. The event also helped reach people who rarely engage with primary care.

There have also been improvements in key outcomes.

We have seen results from our efforts to detect AF in the community. By supplying every practice with handheld AF devices and using them during routine contacts, we identified 446 patients with previously undiagnosed AF. This has enabled earlier anticoagulation and stroke prevention.

Our focus on kidney health has also reaped benefits. The PCN-wide KFRE review led to a 39% reduction in patients at risk of kidney failure within both two- and five-year projections. Earlier nephrology input, tighter monitoring and personalised plans have freed capacity for those most in need.

And the CKD MDT pilot was rolled out across all five practices, covering a total of 1,572 patients on the CKD list. For the project, we are focusing on the following baseline data:

  • Total number of patients coded with CKD, broken down by stage
  • Number of patients with CKD on ACEi/ARB
  • Number of patients with CKD on SGLT2i
  • Number of patients with CKD on Finerenone

Future

Through collaboration with a wide range of partners, we’ve created a more joined-up, responsive way of working that puts patients at the heart of everything we do. It has enabled our workforce to deliver proactive and preventative care, especially to those with complex health issues.

This continues to evolve. We have identified broader patient cohorts for a potential broadening of the CKD MDT approach using practice-level CKD data across other PCNs within Black Country boroughs.

And our latest initiative with Aquarius – a charity supporting people affected by alcohol, drugs and gambling - provides gambling support. It is helping us reach patients in more meaningful ways, offering face-to-face advice, self-referrals, and help for those affected.

We’ve learned that integration isn’t just about formal pathways - it’s about trust, communication and shared purpose. That’s what has made the difference, and what we’ll continue to build on.

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.