A GP from the Wargrave Practice in Berkshire West tells how the Population Health Management programme is working on the frontline with local solutions re-engaging people living with diabetes.
If any of you have watched BBC 1’s ‘Doctor in the House’ Dr Rangan Chatterjee you’ll know he’s a huge advocate of lifestyle medicine – and so am I.
The Royal College of GPs accredited “Prescribing lifestyle medicine course” run by Dr Chatterjee, Ayan Panja and Michael Ash gave me a framework for optimising patients’ health by focussing on four key areas of their lifestyle: sleep, diet, movement and relaxation.
However, putting this into practice has been a real challenge in 10-minute consultations.
Many of us know the importance of the basics of exercise and diet to good health, but there are sections of the population who really need to use it to prevent their conditions getting worse.
While it could be an option to target all patients in these groups with lifestyle medicine it’s simply not possible – but using a Population Health Management (PHM) approach in Berkshire West through the NHS England development programme – we were able to find ten patients in one GP surgery who really needed help.
The PHM approach helps us understand our current – and predict our future – health and care needs so we can take action in tailoring care better for people.
It’s how we use historical and current data to understand what factors are driving poor outcomes in different population groups.
What we did in our Primary Care Network – by getting together data analysts, GPs, hospital consultants, local authority colleagues and many more – was join up our data in a new way.
Using new techniques like actuarial analysis and segmentation the data showed us that Type 2 diabetes was a driving factor behind hospital admissions and NHS use locally.
While Type 2 Diabetes costs the NHS £10 billion a year – a tenth of its entire budget – this insight was out of context for our affluent demographic compared with other similar areas.
What it didn’t show was why. We say PHM is 10% data and 90% behaviour: once we had the data insight, we as local clinicians discussed what could be done about it.
At our practice in Wargrave we spoke to 10 patients out of 75 that the data flagged as concerning and learned that long commutes sometimes meant they struggled to attend day time appointments, so they had sometimes disengaged.
They also said they wanted a deeper level of education around their lifestyle which they felt wasn’t offered by the current NHS.
In our Primary Care Network we discussed local options to tackle this and because of my training in lifestyle medicine, we decided an evening group consultation lasting 1.5hrs with time for questions plus one-to-one with the lead diabetes nurse and GP in the practice could cover all these points.
We wanted to understand from them why their diabetes wasn’t as controlled as it could be and how we could help.
My approach described how sleep deprivation, stress, physical inactivity, low muscle mass, too much highly processed foods, animal fat and a disturbed gut microbiome can all cause insulin resistance causing type 2 diabetes.
Most GPs don’t have time to give this advice in any detail because we’re so time constrained, and while a lot of patients know about diet and exercise, information on stress and sleep is new to them.
Very simple interventions patients can introduce quite easily can make a real change to their diabetes.
As a GP I really enjoyed delivering the session and feel like I had the chance to make a key impact on the health of ten people who really needed it.
The patient feedback was fantastic because they felt like they were listened to and had a voice in their care; plus it’s been amazing to see how their HBA1C levels have dropped.
Some of this was down to my inspiration from Dr Chatterjee but not all of course!
Using the PHM approach allowed us to find and help the right people and also inspired us as GPs – we really feel like we’ve made a difference.