Our Services

Understanding and caring for your mental health is equally as important as your physical health.

Our Advanced Nurse Practitioner specialises in mental health, and can assist with new or reoccurring symptoms and can signpost or refer patients (over 18) to agencies that can provide support, such as our Health and Wellbeing coach or the Community Mental Health Teams (CMHTs). 

If you are taking medication for your mental health, it is important this is regularly reviewed with a clinician to ensure the medication is working correctly.   

• NHS Website – Mental Health Services 
• Biggleswade CMHT
• Mid-Bedfordshire Older Peoples CMHT

A Cancer Care Review (CCR) is a conversation between a patient and a Health or Social Care professional about their experience with cancer. It is essential to personalised care and helps patients to: 

• Talk about their cancer experience and concerns 
• Understand what support is available in their community 
• Receive the information they need to begin supported self-management 

Our Cancer Care Co-Ordinator conducts these reviews and will liaise with other personalised care roles and the patient’s GP surgery. They can also signpost the patient to other services available to them.

Sandhills PCN are aiming to promote participation in cancer screening programmes to help identify cancers early. Identifying cancers early is important for improving treatment options and is more likely to be successful in the long term. 

For more information on cancer screening programmes, please visit: 

• NHS Website – Cervical Screening 
• Cancer Research UK – Cervical Screening 
• NHS Website – Breast Screening 
• Cancer Research UK – Breast Screening 
• NHS Website – Bowel Screening 
• Cancer Research UK – Bowel Screening 
• Coppafeel! 

Care Co-Ordinators connect patients with the help, care and support they need to manage their health conditions and to make decisions about their own care.

This service can help patients if they are:

• Over 18
• Need help finding their way around different health, social care and support services
• Have one or more long term conditions (e.g. diabetes, asthma, COPD, CVD, dementia, chronic pain)
• Help you attend cancer screening programmes
• Help you attend medical appointments

A Care Co-ordinator can work with you to create a care and support plan that is centred around what matters to you. They can work closely with your care givers and the important people in your life, to make sure you receive the best possible care. They can support you in navigating the health system and accessing local support and services.

The Pharmacy Service (consisting of Clinical Pharmacists and Pharmacy Technicians) aims to support patients to gain the maximum benefit from their prescribed medication and to provide patients with advice about their medication.

Working closely with the patient’s General Practitioner (GP), the pharmacy team will optimise and review the patient’s medicines, ensuring that the patient is taking medication safely and appropriately, and that their health and the medication is being monitored.

Clinical Pharmacists primarily do this by conducting in-depth structured medication reviews of those patients who may be having problems with their medication or are taking large numbers of different medicines (polypharmacy).

When issues are highlighted, particularly those pertaining to safety, the team will discuss this with the patient and agree a plan of how to manage the problem. These appointments are strictly used to discuss medications and are essential for medications to be reauthorised.

Some patients may require blood tests and/or blood pressure readings to assess the safety and effectiveness of the medication.

In addition to supporting patients directly, the Pharmacy Service also provides medication information and advice to all primary healthcare staff including GPs, nurses, and administration staff in practices.

Patients may be referred to the service by their GP, practice staff, or patients may refer themselves if they have a concern about their medication.

Our PCN Emergency Care Practitioner is employed and shared across both Practices.

Their role includes seeing patients face to face where room availability allows, increasing the number of appointments for patients to book into with minor illness and injuries.

This service is led by nominated GPs at the practice level. This programme of work will include: 

• Regular ward rounds 
• Training Care Homes staff to better recognise the earliest signs of illness 
• Creating bespoke individual care plans to maintain good health and maximise quality of life 
• Future program is to collaborating with community and voluntary services to bring activities and interests to Care Homes which will enrich the residents’ lives 
• Developing better links between GP Practices and Care Homes to enhance their medical care 

The key focus of this project is to help make Care Homes a place where residents and staff alike can thrive. 

Sarah S is our dedicated care co-ordinator for direct liaison with the Practices, families and Care Homes. 

Musculoskeletal (MSK) conditions affect over 20 million people in the UK and can range from minor injuries to long-term conditions. Sandhills PCN has commissioned Circle Bedfordshire MSK to provide appointments for you to see Advanced First Contact Practitioners.

These can be booked directly by calling your Practice or may be arranged for you after you have seen another Clinician. 

Our Health and Wellbeing Coach, Gemma, supports patients to self manage, change behaviours, motivate and commit to lifestyle changes, focusing on health-related outcomes.

Together with the patient, our health and wellbeing coach will produce a personalised plan including goals to work on and how to achieve these goals. The patient will typically have 6 sessions fortnightly with a follow up call 6 months later to check in. 

We are aiming to support our member practices by giving patients the tools they need to help themselves. 

We are committed to identifying health inequalities in our patient population. This means looking at our patient groups within the Core20PLUS5.

• For 2023-2024 we focused on Improving Digital Literacy in our patients.
• For 2024-2025 our focus is on Improving the Wellbeing of our COPD patients, including the launch of our Breathe Easy Group, and Hypertension Inequalities Project.

Hypertension

Sandhills PCN are working on identifying patients with hypertension for early intervention and treatment. We identify these patients by requesting 7 days of blood pressure readings taken at home. Persistent high blood pressure increases the risk of other serious health conditions, so it is important to check your blood pressure regularly. 

If your blood pressure is over 140/90mmHg, your practice may offer you a face-to-face blood pressure appointment or signpost you to the community pharmacy hypertension scheme.

For more information on hypertension, please visit: NHS Website – Hypertension (high blood pressure) 

Atrial Fibrillation

We are also working on identifying patients that are at risk of atrial fibrillation for early intervention and treatment. We identify these patients through outreach clinics and by checking a patient’s pulse along with their blood pressure. If atrial fibrillation is suspected, your practice may give you an electrocardiogram (ECG) and refer you to a cardiologist for more tests.

For more information on atrial fibrillation, please visit: NHS Website – Atrial Fibrillation

The NHS App

The NHS App is available to anyone over the age of 13 and registered with an NHS GP practice in England. It is a safe and simple way for people to access a range of NHS services on smartphone, tablet or computer. 

The NHS App enables people to access digital health and care services. This helps them to stay well, get well and manage their health. 

View our PowerPoint Presentation and Walkthrough Document.

For more information on the NHS App, please visit:

• NHS App Help and Support 
• NHS App Features 

What is Social Prescribing?

Social prescribing connects people to activities, groups and services in their community to meet the practical, social and emotional needs that affect their mental health. Health services can refer patients to a social prescribing link worker who will work with the patient to produce a personalised care and support plan.  

Patients aged 18 and over can self-refer or be referred to support in the community, to improve their health and wellbeing 

For more information, please visit:

Central Bedfordshire Council – Social Prescribing 

Your Wellbeing Bedfordshire