By KLTV Newsdesk –

Innovative SPEN Primary Care Network initiative recognised for transforming care for vulnerable patients

An innovative healthcare programme supporting frail patients across North Kirklees has received national recognition after winning the prestigious SystmOne GP Excellence Award.

SPEN Primary Care Network (PCN) was announced as the winner following a vote by SystmOne users, with judges recognising its collaborative approach to improving care for patients living with frailty.

The award follows a presentation showcasing how the network has brought together GPs, patients and a wide range of service providers to deliver more personalised and effective support for some of the area’s most vulnerable residents.

Addressing the complex needs of frail patients

Around one in eight patients registered with SPEN PCN has a frailty diagnosis. Seeking to better understand the challenges these individuals face, the network engaged directly with patients to gain deeper insight into the factors affecting their health and wellbeing.

Working closely with each of its seven GP practices, the PCN developed tailored patient lists and established multidisciplinary teams tasked with taking a holistic approach to patient care.

The initiative focuses on identifying those who would benefit most from coordinated support and bringing together professionals from different disciplines to improve outcomes and quality of life.

A holistic approach delivers early results

Through the engagement process, the network discovered that mental health and social care issues were often just as important as medical treatment in determining patient wellbeing.

Alongside GP-led support, patients were offered access to physiotherapy and rehabilitation services, personalised care plans and comprehensive medication reviews.

By streamlining services and improving communication between providers, the programme has reduced duplication and helped minimise the need for additional healthcare appointments.

The results have been so encouraging that plans are already underway to expand the model across North Kirklees.

‘Validation that what we are doing is good’

Dr Danielle Nimmons, Academic GP at Liversedge Medical Centre, PCN Clinical Director and the lead clinician behind the project, welcomed the national recognition.

She said: “Everyone is so happy. Delighted. It is validation that what we are doing is good.

“It’s beneficial seeing the providers working well together. We all feel equal in what we bring to this work, and we all have a voice. Each partner is an expert in their field, and it is empowering them to improve the lives of our patients.

“We’ve seen positive results within just six months, and we are looking to roll this out across all the PCNs in North Kirklees. I can even see this approach being adopted in other areas of West Yorkshire or maybe even further afield.”

Research-led innovation with national potential

Alongside her role as a GP at Liversedge Medical Centre, Dr Nimmons is also a researcher at the University of Leeds, supported through the National Institute for Health and Care Research (NIHR) Applied Research Collaboration in Yorkshire and Humber, and works as an NIHR Clinical Lecturer.

The combination of frontline clinical experience and academic research has helped shape an evidence-based approach that is already delivering measurable improvements for patients.

A presentation delivered by Dr Nimmons as part of the award submission process is available to view on YouTube.

Looking ahead

Following their national success, Dr Nimmons and her colleagues are now focused on expanding the programme’s reach, with ambitions to roll out the model across other Primary Care Networks in Kirklees and potentially throughout Yorkshire and beyond.

The award not only recognises the achievements of the SPEN PCN team but also highlights the growing importance of collaborative, person-centred care in meeting the increasingly complex needs of an ageing population.

As healthcare providers continue to explore new ways of supporting vulnerable patients, the success of the Kirklees initiative could provide a blueprint for communities across the country.