Warwickshire East PCN is one of the 10 networks shortlisted for PCN of the year. By maximising the potential of ARRS pharmacists, it has redesigned care delivery in the management of long-term conditions and frailty in care homes. Clinical director Dr Rajeev Kanwar explains more.

Warwickshire East PCN unites five GP practices in a semi-rural area. We see our strength as being our determination to turn local challenges - geography, workforce, and patient needs - into opportunities for service redesign.

We have redesigned several areas of care delivery where we saw room for improvement, notably in care home frailty and the management of long-term conditions. By maximising the potential of our ARRS pharmacists, we have found practical and sustainable solutions.

Aims

We identified some challenges in two groups of patients – those in care homes and working adults with long-term conditions.

Frail residents in care homes were experiencing fragmented care, often involving multiple uncoordinated providers. And at the same time, we recognised that health inequalities were being exacerbated as working adults struggled to access appointments to manage long-term conditions.

Our aim was to develop an inclusive model of care through multidisciplinary teams and a blend of digital innovation and community-based access. This is the approach we took when, together with partners, we co-designed an integrated and inclusive approach to mental health care.

Now, our pharmacists deliver high-impact clinical care in care homes and extended access settings.

By investing in training – such as atrial fibrillation (AF) detection, structured medication review templates, and deprescribing protocols – our ARRS pharmacists have helped reduce polypharmacy and improve QOF coding.

Frailty

To address the challenges in care homes, we developed a frailty multi-disciplinary team (MDT) model. This is jointly delivered by a GP lead, a care home clinical pharmacist and a frailty nurse. The team works closely with local care home teams, with care home staff joining meetings on a monthly basis.

Our care home pharmacist, Mina Hunjan, delivers weekly structured medication reviews as part of the frailty MDT. She uses AF detection tools, deprescribes based on frailty risk, and engages families in shared decision making. This continuity has led to safer prescribing and improved confidence among both residents and carers. Her work, which has been featured by the British Geriatrics Society, has reduced polypharmacy while enhancing quality of life.  

She also collaborates with local anticoagulation and diabetes services to ensure continuity when initiating or adjusting medications. This integrated infrastructure ensures shared responsibility across health and care providers. It improves communication, efficiency, and patient experience.

Long-term conditions

To address access challenges for patients with long-term conditions who were having difficulty getting appointments at convenient times, we turned to pharmacists again. We expanded support for long-term condition management by embedding clinical pharmacists and health coaches into our extended access service.

Rather than using evenings and weekends to firefight urgent demand, we proactively designed structured clinics. Pharmacists now run structured medication reviews and long-term condition reviews during these sessions. This has been particularly valuable for working patients. As well as boosting access, it has freed up GP time during core hours.

Evenings and weekend sessions are also when health and wellbeing coaches deliver one-to-one coaching and run specialist groups on menopause, weight loss and chronic pain with integrated psychological support where needed.

The combination of evening sessions and digital recall tools, such as Medilinks, ensures inclusivity for working patients. Searches at PCN-level optimise coding and prescribing safety, supported by real-time QOF reviews.

Outcomes

Our redesigned approach has improved outcomes and supported workforce resilience across five practices.

In care homes and frailty, our work has led to AF detection and direct oral anticoagulants (DOAC) initiation for undiagnosed patients using mobile Kardia devices. Proactive deprescribing plans, which are shared with families, have reduced polypharmacy, falls, and unnecessary monitoring.

And the weekend and evening extended access clinics delivered by pharmacists and health coaches have resulted in an increase in uptake of structured medication reviews, especially among working patients. For example, before implementing these clinics, my practice had around 1,200 patients on the QOF register with overdue medication reviews. That figure has now fallen to around 450.

Group and one-to-one sessions have proved popular - 170 patients have participated in group sessions and 672 patients have had one-to-one appointments.

There has also been a positive impact on workforce. Automation tools such as Medilinks and GP Automate have reduced admin burden, allowing clinicians to focus on patient-facing care.

Clinical staff – particularly pharmacists and advanced nurse practitioners – have reported improved morale. Staff retention at practice level has also improved.

Future

We have seen a ripple effect from this work. We start small – usually at one practice - which helps demonstrate impact and build momentum before expanding the model across the whole PCN.  

For example, we trialled Medilinks at one practice and, when we saw it was a success, we trained a dedicated PCN pharmacy technician to review the patient responses. Now, the system is being trialled at a second practice, using the same pharmacy technician for support. If successful, it will be rolled out across the remaining sites with the PCN pharmacy technician monitoring progress.

Looking ahead, we are piloting continuous glucose monitors (CGMs) for prediabetic patients to provide visual biofeedback on dietary impact, empowering patients with personalised nutritional education.

Our model shows that with co-designed systems, shared workforce planning, and smart digital tools, PCNs can remove barriers and deliver truly joined-up, patient-centred care at scale.

Our tips

  • Empower non-GP clinicians. By investing in training, you can see benefits such as reduced polypharmacy and improved QOF coding. It also boosts their job satisfaction.
  • Meet patients where they are - digitally and emotionally. Whether it’s a care home resident crocheting during a medication review, or a patient completing an asthma survey at 11pm, flexible, human-centred approaches create better engagement. Patients engage more when they feel respected, not rushed.
  • Pilot, prove, then scale. Starting small allowed us to adapt, prove impact, and gain buy-in before expanding the model across all five practices. This staged approach built credibility and made the model sustainable.

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.