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Clinical directors should consider applying a population health management approach to their wider service delivery, according to NHS England guidance on the Network DES.
The new contract stated that PCNs must deliver four key functions in regard to how they operate and organise effectively (see box below).
In a guidance document on the Network DES, NHS England outlined further details on the last two of these functions: to improve health outcomes through effective population health management and target resources in the most effective way, including delivering proactive care.
The DES specifies that a PCN must deliver four key functions. Two of those functions relate to how the PCN organises and operates effectively:
Population health management
The guidance, intended to describe best practice for these specifications, called on PCNs to use a ‘data-driven’ approach and ‘population management techniques’ to improve health outcomes.
It stated that PCNs are expected to engage with wider delivery partners, including secondary, community and mental health services, and agree formal data sharing arrangements with Integrated Care Boards (ICBs) to support local integration of data.
ICBs are also expected to support PCNs to use the data.
The guidance said that e-learning modules are available for PCNs, via the e-learning for health hub, on the principles of population health management.
It also called on PCNs to work in partnership with local communities to address health inequalities. It suggested that the Core20PLUS5 approach was a ‘helpful focal point for galvanising action and guiding targeting’.
This approach defines the 20 percent most deprived in their population, ‘PLUS’ groups, such as ethnic minority communities and those with a learning disability, and five clinical areas that require ‘accelerated improvement’, including maternity care, severe mental illness and early cancer diagnosis.
Targeting resources
The DES also stated that PCNs must contribute to the delivery of ‘multidisciplinary proactive care’ to complex patients most at risk of deterioration and hospital admission, which must be done as part of integrated neighbourhood teams.
The guidance stated that PCNs should use analysis of local data sets and evidence-based risk prediction tools for this service delivery.
It said: ‘A PCN should refer to the proactive care guidance to identify and code the target cohort, develop a personalised care and support plan, deliver co-ordinated multi-professional interventions and provide a clear plan for continuity of care. Depending on local capacity to implement proactive care, further prioritisation may be needed based on risk of deterioration.
‘A PCN should utilise analysis of local data sets (as developed by ICS analytical teams where applicable), evidence-based risk prediction tools such as the electronic frailty index, the EFI2 (when published), clinical validation tools and local knowledge, and practitioners should use the SNOMED codes outlined in the appendix.’
Supporting and improving resilience and care delivery
A PCN (led by the clinical director and as described in section 5.3 of this Network Contract DES Specification) must work with, and support, its Core Network Practices to improve the quality and effectiveness of its delivery of the Network Contract DES, whether components are delivered at PCN or practice level.
To achieve this, the PCN must continuously work to improve patient experience and the care that patients receive. This involves ensuring effective allocation of funding and Additional Roles Reimbursement Scheme capacity across the PCN as well as supporting the effective configuration of practice capacity. It also involves supporting the application of peer-review and continuous improvement techniques across Core Network Practices.
Improving health outcomes and reducing health inequalities
A PCN must seek to improve health outcomes for its population using a data-driven approach and population health management techniques in line with guidance and the CORE20PLUS5 approach. The approach must include, but is not limited to, the following activities:
A PCN should actively seek to reduce health inequalities across its Core Network Practices in line with guidance and the CORE20PLUS5 approach. To address health inequalities, a PCN should work in partnership within local communities to deliver effective outreach and target care to address health inequalities that are amendable to primary care intervention.
Targeting resource and efforts
A PCN must contribute to the delivery of multi-disciplinary proactive care for complex patients at greatest risk of deterioration and hospital admission, by risk stratifying patients and offering care in accordance with the guidance. This must be done as part of INTs, with the aim of reducing avoidable exacerbations of ill health, improving quality of care and patient experience, and reducing unnecessary hospital admission.
Other key requirements of a PCN are to:
III. co-ordinating an MDT meeting and associated actions, including the lead GP or clinician and care home staff;
Collaboration with non-GP providers to provide better care
A PCN must work with other PCNs, local community services providers, mental health providers, community pharmacy providers and other relevant health and social care delivery partners in the best interests of patient care. This includes developing and fostering strong relationships with other clinical leaders and commissioners to successfully manage the health and care needs of the populations they serve.
Source: Network DES
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