How this PCN approaches the care of high users of health services

Central, Thistlemoor and Thorpe PCN in Peterborough, Cambridgeshire is one of the seven networks shortlisted for PCN of the year. It uses population health management to support high users of health services in its area. Clinical director Dr Neil Modha explains the impact of this work on health services and patients

Central, Thistlemoor and Thorpe PCN looks after some of Peterborough’s most deprived and challenged populations. The three practices – Central Medical Centre (15,000 patients), Thistlemoor Medical Centre (30,000 patients) and Thorpe Road Surgery (10,000 patients) – are located within an inner-city environment and serve a diverse population. A large proportion of the community are non-English speaking with a high number from a BAME and Eastern European background.

In 2022/23 the PCN, supported by the Integrated Neighbourhood Team and working in partnership with others, took a population health management (PHM) approach to change care delivery for some of the most challenged and deprived members of the population, prioritising those who use GP and hospital services the most.

As a result, it saw a decrease in appointment frequency at general practice of about 75% and attendance at A&E dropped by almost a third.

Method

We identified a cohort of 393 high-use patients. These people were high-intensity users of primary care services, with more than 10 encounters a year and who had attended the emergency department (ED) more than twice in the past year and were from the low complexity segment (0-1 long-term conditions). We also considered the wider determinants of health. The chosen cohort was specifically impacted by deprivation, housing issues, and working in industries that make access to the health and care system difficult.

The opportunity for scalable impact was clear, with the focus on developing a neighbourhood team that improves the response to people who need proactive and preventative management. This project integrated wider primary care, local authority, and voluntary organisations.

Of the nearly 400-patient cohort, 290 participants engaged with the programme. Most of the cohort received support by referral to social prescribing services, which identified social, financial, housing, and employment-related issues.

Ultimately, the initiative helped the team and cohort focus on preventative measures rather than referrals to hospitals or tests such as scans or blood tests.

Aims

The core objective of the programme was to accelerate changes to care delivery at the neighbourhood level through PCNs to achieve better outcomes and experiences for the selected population cohorts and secure the skills to spread the approach to other cohorts.

We hoped our approach would reduce unnecessary visits and appointments with general practice and ED and improve the recording of wider determinants of health in GP records. We also hoped the initiative would result in a greater integration of services across organisational boundaries. By improving self-management and encouraging preventative proactive care, we sought to reduce health inequalities across population groups.

For patients, we wanted to empower individuals to take better control of their own health and wellbeing and help them make a more appropriate use of time and resources.

Approach

We took part in the PHM Development Programme commissioned by NHS England and NHS Improvement which was an intensive 22-week programme to enable systems, PCNs and partners to make faster and more effective progress in the use of PHM techniques.

This supported the PCN in the use of tailored analytics to rapidly put PHM into practice, using a data-driven approach to reduce demand on primary and secondary care ahead of winter 2022/23. 

Four GP trainees with an interest in health inequalities and helping deprived communities provided leadership to a team comprising GP trainees, social prescribers and health coaches. The team contacted people directly through text messages and phone calls, using their System One database, offering one-to-one consultations that aimed to prioritise their wellbeing.

Appointments were booked in advance (up to one week ahead) so the PCN could provide language support if needed. The workforce at our practices reflects the high diversity of the location and the 120+ languages spoken in the area so we could tap into the skills of our multilingual staff. 

Sessions are confidential but informal one-to-one chats about how we can better support patients rather than waiting for a referral. The focus was holistic, undertaking strength-based training and health coaching, making every contact count. Longer appointment times were facilitated, enabling listening and support for the cohort. The team was keen to understand the cohort’s level of health and wellbeing.

We used the JOY social prescribing application, which allows for easy referral to one-to-one sessions and more seamless data analysis and information collection during drop-ins.

Partnership working

As well as the project helping patients, it has helped us learn from partners in the system.

We now understand more about the wider determinants of health and wellbeing and the effects that this has on our patients and our community. And the council supported us with motivational interview techniques and the voluntary sector taught us the opportunities for patients in the community.  

The PCN held regular meetings with relevant stakeholders to discuss the progress of the project, address any issues or to flag areas where better outcomes could be achieved. For example, we found there was an increased level of sick notes among cohort members who had been issued medical certificates in the last six months. We wanted to identify members before they were issued a second extension to their fit note.

So, we arranged an on-site one-to-one discussion at Thistlemoor with wider neighbourhood partners, such as an employment or skills advisor from Richmond Fellowship or Peterborough City College. The aim was to talk to patients about employment issues, such as retaining their job or upskilling or providing information about courses that might prepare them for returning to work.

To address social issues in our community, the PCN continues to facilitate weekly one-to-one sessions with a council representative to discuss housing, fuel poverty, and social care needs. The voluntary sector provides Tai chi and yoga support at no cost with sessions occurring within practice grounds, making it an anchor for the local community.

Key learning

Engaging with patients in such a way that they feel no sense of judgement is crucial. We found communicating to offer support was an effective approach. 

We also learned that it was essential to make it simple for people to choose ‘yes’ or ‘no’ on a first contact text message. This was especially true for those with a language discrepancy, learning difficulty, or access barrier. And given many of the cohort and local population are shift workers, offering flexibility of appointments was important.

Bringing in partners from the local authority increased solution options and we found using a wide variety of roles in the practices helped to upskill the workforce.

And we learned that ensuring staff had training in motivational interviewing was important to equip them for shared decision-making. This enabled more comprehensive support.

Outcomes

After the intervention, GP clinic attendance substantially reduced from more than twice a week on average to 0.6 times a week, translating to a decrease in appointment frequency of about 75%. The group also used emergency services less – their emergency department attendance decreased by 30% for the same period.

We achieved a CollaboRATE score (a brief patient-reported measure of shared decision-making) of 7.6 on feedback forms in April 2023, increasing to 8.2 in August, just four months later.

We also had success as a result of the sick note aspect of the initiative.

In August 2023, there were 1,876 patients over the age of 19 years who had a MED3 (fit note) issued in the last six months. During this time, 76 patients from the group had either a depression, physical or mental health code added to their patient record. Of the 76, 81% agreed to take part in a work and health project. Outcomes included an increase in happiness and life satisfaction and a reduced level of anxiety.

There was a 10% reduction in repeat fit notes and from August 2023-March 2024 we have seen total of 84 patients in this project, with 103 consultations provided and 30% of these patients are currently satisfied in a new job (see outcomes below).

Future

There are plans to apply a population management approach to lifestyle measures to support patients with smoking, alcohol, exercise, and diet.

Using the same methodology, the PCN will identify which interventions suit patients the most and work with other providers, such as the voluntary sector, local football clubs, and other lifestyle organisations, to support interventions tailored to our population.

 Profiles of the shortlisted PCNs will feature on Pulse PCN in the run up to the awards night on December 6.