PCN Services

PCN Services

Patient Ambassadors (Our Social Prescribers)

Please scroll on the PDF below to view the entire document!

Hamara | Patient Ambassador Video

Social Prescribers

How we can help.

  • Help and support with non-medical issues e.g. housing, debts, mental health, bereavement, refugee/asylum seeker issues and benefits.
  • Support clients to access Health & Social Care where needed. This will include supporting patients at meetings and acting as advocates.
  • Offer peer support groups e.g. sleep well and mental health
  • Work with other third sector organisations in the community to break down barriers for patients and help them to access information they need.
First Contact Practitioners (Physios)

How we can help.

  • To assess patients with soft tissue, muscle and joint pain and to decide on the most appropriate management pathway.
  • FCPs are physiotherapists with expertise in the assessment and management of Musculoskeletal (MSK) conditions. 

FCP Rotas

Mental Health

Leeds Mental Wellbeing Service (LMWS)

How we can help.

  • We address the mental health needs of patients with complex histories, co-morbidity, patients who haven’t previously met criteria for or have disengaged with IAPT or CMHTs.
  • Support patients who find it difficult navigating into mental health services by themselves.  

Trauma Informed Approach

Trauma Charter

As a PCN, we are committed to implementing trauma informed care and agree to the commitment described in the charter.

Healthy Minds

Healthy Minds appointments are available Monday – Friday during core hours. These appointments support patients who are struggling with low level mental health and emotional wellbeing difficulties.

DO NOT BOOK under 18s, patients who are expressing thoughts of self-harm, or patients who are under the secondary care mental health team. Any questions reach out to [email protected].



HEROES Level 1

How we can help:

  • The HEROES Peer Support Programme is a series of courses, workshops and generalised support groups for patients struggling with their mental health.
  • HEROES stands for Healing, Education and Recovery Of Emotional Strength and it also stands for the kind of person who joins our groups!
  • Groups are run by trained facilitators in a safe, compassionate and recovery-focused space.

We explore topics such as Self-Compassionate practice, Mindfulness, Anxiety Management, Confidence Building and Assertiveness Skills. New courses will be added throughout the year.

Please contact Miranda [email protected] for further details/fliers/programmes or Patchs self-referral template to text to patients.

We look forward to welcoming more patients who may be suffering emotionally. All mental health diagnoses welcome!

HEROES Level 2

HEROES Level 2 is now being piloted and co-produced with patients from the BHR PCN. Following the success and outcomes of the 8 week HEROES Groupwork Programme, founder Miranda Arieh is now piloting this follow up.

Within this level we will explore further applying the motivational coaching approach to mental health recovery, while exploring topics such as trauma release, managing anger, nervous system regulation, meditation, how to create a positive mindset, dealing with triggers, managing emotional flashbacks and much more.

You need to have graduated from level one of the HEROES Programme prior to entering level 2.

Find out more at www.heroesnetwork.co.uk or ask your GP for further info.


BHR PCN have a small team to support patients that have a diagnosis of a serious mental illness (SMI): Schizophrenia, bipolar disorder and other psychoses. Around 400,00 people in England are living with Schizophrenia and around 544,631 people are living with bipolar disorder. People living with a SMI are at considerably increased risk of physical ill health than the general population and have demonstrably poorer health and health outcomes. Our team of healthcare assistants, nursing associates and care coordinators are a dedicate team that are here to help our patients to access primary care services and reduce health inequalities for this population. 

The team focus is supporting patients to have annual health reviews which include a physical health check: Bloods test, Blood Pressure, check patients are accessing cancer screening appointments. It also includes a review of their mental health care plans and includes development of personalised care plans. The team do this by assisting patients to seek help with lifestyles changes, emotional support and can support patients in accessing health and wellbeing coaching.

Importance of having a annual health check:

video promoting importance of physical health checks for SMI patients

Why is it important for you to attend for your SMI health review

Extended Access Services (All held at Bellbrooke)

We Offer

  • Paediatric Clinic:
    Monday to Friday, 16:00 – 18:00 (routine appointments only)
  • HCA routine appointments 
  • Smears
  • LARC, GP Sexual Health Clinic, coils & implants insertion/removal:
    Saturday, 9:00 – 15:00 (with 1 HCA Chaperone & Stock replenishing)
  • GP appointments:
    Monday to Friday, 18:00 – 20:00
    Saturday, 9:00 – 15:00 (Routine appointments)
    Sunday, 9:00 – 13:00
  • Practice Nurse:
    Saturday, 9:00 – 15:00
    Sunday, 9:00 – 13:00
  • HCA:
    Saturday, 9:00 – 15:00
    Sunday, 9:00 – 13:00
Pharmacy Team

How we can help.

  • Support practices with medication related process such as medication queries, medication reviews and repeat prescription reauthorisations. Supporting practices with processing clinical documents and structured medication reviews.
  • Safety audits including MHRA and amber drug monitoring.
  • Project work highlighted by national quality and safety directives.
  • Supporting with all aspects of prescribing for the care homes team.
Health & Wellbeing Coaches

Health and Wellbeing Coaches

What is a Health and Wellbeing Coach?

A health and wellbeing coach can support you to improve how you manage your physical and mental health. They work with you through a series of sessions to help achieve your personalised health and care plan goals, offering support and advice about diet and lifestyle.

How can a health and wellbeing coach support me?

Health and wellbeing coaches support you to take proactive steps to improve the way you manage your physical and mental health conditions based on what matters to you.

They support you to develop knowledge, skills and confidence in managing your health and care, to improve your health and quality of life. They will coach and motivate you through multiple sessions to identify your needs, set goals and support you to achieve your personalised health are care objectives – providing interventions such as self-management education and peer support.

  • 1:1 and group coaching
  • Support setting personalised health goals
  • Linking in with other services
  • Support to manage your long-term health condition
  • Support towards eating well, staying active or managing your weight
  • Support to manage your mental wellbeing
  • Adhere to a care plan

Where is a health and wellbeing coach based?

Health and wellbeing coaches are based within your local community. They work out of local GP surgeries so you may have an appointment at a different surgery to where you are registered.

How do I make an appointment to see a health and wellbeing coach? 

Health and wellbeing coaches are accessible via your GP Surgery, when ringing for an appointment the reception team may suggest you speak to a health and wellbeing coach and a member of the team will then be in touch with more information and to find out if health coaching will be suitable for you. You can also make a self-referral by calling 01132405080.

What can I expect from an appointment with a health and wellbeing coach?

During the first session with a health and wellbeing coach they will find out more about you, your lifestyle, values, goals and anything that might get in the way of achieving those goals. You will then set some short-term goals that will enable you to start to work towards what it is you want to achieve. In the sessions that follow you will review your progress, set new goals and discuss any challenges you might have faced to help you overcome these in the future. In doing so, health coaching helps you develop the skills and confidence to manage your health and wellbeing.

Will I need to see a health and wellbeing coach on a regular basis?

You will be offered 6-8 sessions of support, consisting of 45-minute consultations via telephone, online or face-to-face. 

Why is the health and wellbeing coach based at my GP surgery?

Primary care networks are prioritising the need for dedicated health and wellbeing provision within their primary care teams. The health and wellbeing coach works closely with the clinical staff in your GP practice to seek advice and guidance on different aspects of your care where necessary.

Cancer Screening

Cancer Care Coordinator

Around 20,800 people are diagnosed with cancer each year in Leeds and 55% of cancers are diagnosed early. Early diagnosis saves lives but screening uptake for breast, cervical and bowel cancers is often low. So, cancer screening is an important priority for our PCN.

Building on the previous ‘Cancer Wise Leeds’ programme (2019 – 2022) BHR PCN are now continuing the legacy work through the employment of a PCN Cancer Care Coordinator and Cancer Champions based in each of our 12 practices.

Cancer screening participation varies depending on multiple demographic and geographical factors. So, the aim is to have specific plans to target support to our population and patients that helps participation to reduce health inequalities.

The role of a Cancer Care Coordinator and cancer champions is to work closely with our patient population/ communities within our area to identify potential barriers to screening. Through this, we will be able to deliver information and education around screenings and tackle potential misconceptions.

What we know:

  • Participation in bowel screening is low in deprived areas, and particularly South Asian communities.
  • Participation in cervical screening is low in deprived areas, however there is variation in rates between ethnic groups.
  • Breast screening is lowest in deprived areas and people from Black or South Asian backgrounds.

The cancer care coordinator will be supported by our colleagues in the PCN, working collaboratively to support our patients. We have a wide access to a variety of resources and want to make our patients feel comfortable and reassured to enable participation in cancer screening.

Long-term Condition Hub

BHR PCN have a small dedicate team of healthcare assistants, nursing associates and care coordinators. They provide support to practices to identify and coordination care for a range of people, particularly those with long-term conditions and multiple long-term conditions. The team help people co-ordinate and navigate their care across the health and care system. 

The approach is to provide support and influence the health of the community and its patients to tackle health inequalities.

Our population have a higher prevalence of long-term conditions particularly at an earlier age and because of the nature of our more deprived communities, along with our culturally diverse population, these multimorbidity patients are typically our hard-to-reach patients. 

The team objectives is to support patients to stay well and manage their condition by working very closely with their GP’s. 

Our Priority is Diabetes

BHR PCN have a specialist diabetes service that runs twice monthly. In the clinic patients are seen by a consultant endocrinologist. Practices refer patients to this clinic that are complex and require a specialist care plan review. The LTC team can support practices in identifying appropriate patients and preparing patients for the specialist clinic.

Our Focus area

Type 2 Diabetes in the Young Initiative

The National Diabetes Audit (NDA) shows that prevalence of type 2 diabetes in younger people is increasing yearly, with an estimated 137,260 people with type 2 diabetes aged 18-39 in England. In west Yorkshire prevalence is estimated at 7500 people; the majority of whom are cared for exclusively in General Practice (GP).

Diabetes in younger people is associated with a more aggressive diabetes phenotype than older-onset type 2 diabetes, including more rapid progression of glycaemia and early development of complications with significant reduction in life expectancy. Despite this, people with EOT2D are less likely to receive all NICE recommended care processes and tend to have higher HbA1c than older people with type 2 diabetes. The PCN LTC team are focused on supporting practices to target this population and improve health outcomes.

Type 2 Diabetes Path to Remission Programme

The NHS Type 2 Diabetes Path to Remission Programme is a joint initiative between NHS England and Diabetes UK. This programme provides a low calorie, total diet replacement treatment for people who are living with type 2 diabetes and obesity or overweight: the NHS Type 2 Diabetes Path to Remission Programme.

The programme is being offered to eligible people, participants will be offered low calorie, total diet replacement products including soups and shakes consisting of 800 to 900 kilocalories a day for 12 weeks. During this time, participants will replace all normal meals with these products. Alongside this, participants will receive support and monitoring for 12 months including help to re-introduce food after the initial 12-week period. This support will provide participants with the help and advice they need throughout every stage of the programme. The programme is fully funded by the NHS, therefore there is no cost to participants.

NHS Diabetes Prevention Programme

The NHS Diabetes Prevention Programme (NHS DPP) is a joint commitment from NHS England, Public Health England and Diabetes UK, to deliver at scale, evidence based behavioural interventions for individuals identified as being at high risk of developing Type 2 diabetes. 

Start Your Journey to a Healther You Leaflet (wypartnership.co.uk) – Urdu

Start Your Journey to a Healther You Leaflet (wypartnership.co.uk) – Punjabi

Vaccinations & Immunisations
 Children’s Health Hub

As the Hub still in development, please follow the below process for the time being for any new referrals you wish to make –


  • Please send a task to the Childrens Health Hub (I have created a new user group for this) outlining the reason you wish to make a referral (Please do not refer the patient into the Hub)
  • Kate and Sanya will read through the notes and assess if the patient is appropriate and respond to the task
  • Kate and Sanya will then complete a referral to the Hub if they deem the patient appropriate (they will notify you if they’re not, by responding to the task)

**Bellbrooke staff – please task either Kate or Sanya directly on EMIS and they will assess if the referral would be appropriate**

Women’s Health