Peterborough

There are three Integrated Neighbourhoods in Peterborough:

Older people – This group will focus on those aged 65+, rather than the NHS standard of 75+, ensuring people can stay well for longer through health and wellbeing activities held by partners within the neighbourhood.
Healthier Lives - This group will focus on those under 18 which makes up 20% of the BMC and 25% of the Paston population, as well as promoting schemes which apply to the majority of the Primary Care Network, such as smoking cessation and weight management.
Tackling inequalities – This group will focus on the six groups identified by Cambridgeshire & Peterborough as being at most risk of Inequalities, as well as those within the CORE20PLUS5 groups.

Falls prevention - To work together over the next year to prevent an increase in falls and the negative impact of falls in adults, to enable older people in Peterborough to enjoy an active, fulfilling life. This will run across all Peterborough PCNs.
Homeless Health Hub – Aims to address agreed health inequalities in Peterborough by providing a mobile health hub for people experiencing, or at risk of, homelessness. including mental health support offered by Greater Peterborough Network.

Awareness and education: To reduce long-term health conditions by raising awareness of self-help e.g. diet, exercise, reduction of alcohol and smoking cessation.
Multidisciplinary working: To enhance our professional teams and work closely together e.g. Community Champions and Health Coaching.
Prevention: To embed preventative services within GP practices to focus on smoking, obesity and cardiovascular disease. To develop champions to be based within the practices to actively promote and triage patients/citizens to appropriate services focussed on prevention.

Waiting Well: to improve the general physical and psychological health and wellbeing via supportive activity.
High intensity users: to ensure specific cohorts of patients have access to appropriate support and services to improve quality of life.
Children and families: to improve the health and wellbeing of children and families in the Central Thistlemoor and Thorpe area.
Long-term condition management: to improve patient outcomes. To meet diabetes targets, manage hypertension and improve the detection of atrial fibrillation.
Digital inclusion: to address digital exclusion which is preventing the uptake of health coaching.
Scale up Community Champion Programme: An expansion of the Volunteer Community Champions (VCC) but to take on a focussed and 1:1 educational programme to reach our less engaged and vulnerable populations.

Smoking cessation
Cost of living and warm hub which are interweaved into all communications and projects
Help with obesity
High intensity users in primary and secondary (hospital) care
Falls prevention
Good Neighbour Scheme
Digital inclusion

Good Neighbours Scheme: To establish this voluntary scheme in Peterborough, working closely with parish councils to provide this service to local people.
Proactive Social Prescribing Project: The social prescribing team are working with Change, Grow Live to offer bespoke sessions to people who would benefit from their bespoke service and where access is challenging.
Innovation fund: Devices project to relaunch from May 2023 to support with improved digital literacy and improved digital access to general practice services. This will be launched in collaboration with local libraries and community champions.
Obesity - PCN projects where signposting to Healthy You, digital weight management and Health Coach support.
Fibromyalgia - high intensity concept to proactively manage those showing as having a high demand on general practice or at risk of doing so. This is a psychotherapy intervention as a group which is now closed and in the evaluation phase.