How GPs designed new frailty models during population health pilot

Dr Yasara Naheed, Clinical Director for Burnley East Primary Care Network discusses designing new frailty models as part of the NHS England Population Health Management (PHM) programme:

In Burnley in Lancashire a large proportion of our patients live with moderate frailty and we wanted to come up with new solutions to improve their quality of life.

We’re all living longer with more complex conditions or frailty and want our patients to live healthier and happier at home in control of their conditions.

People with moderate frailty are generally older people who often have a combination of physical and mental health needs and are at a higher risk of falls, disability, admission to hospital, or the need for long-term care.

Patients could present to me in surgery after a fall, infection or other incidents at home or they might just end up in A&E usually because they’re panicky or feel vulnerable.

We wanted to better understand the experience of the frail and vulnerable people in our communities and try to identify a simpler proactive care model solution to these very complex needs.

Being a part of the Population Health Management pilot gave us a great opportunity to do this by scrutinising available data insights in new ways.

We knew our experience as health professionals needed to be triangulated with the available data and lived experience so we’d have a richer, deeper and broader understanding of the challenges – and the solutions.

It was fascinating to sit down with data analysts, public health, communication, council and finance colleagues we previously would not have met with and think through which datasets would give us the most rounded view of this cohort.

What we were looking for was a data driven approach to map out detailed patient stories, lived experience and the possible impacts of interventions. We wanted to manage these patients with the help of our local primary care teams to reduce the risk of falls and advise on fracture prevention to prevent further complications.
The results showed that some patients can live well with frailty with support from community services and primary care but others need more support.

After interrogating the data in numerous ways to identify those most at risk we drew up a list of people to contact and from the surgery wrote to them inviting them to a peer support engagement event.

We offered the event both in the GP surgery and a community centre near the surgery because we knew there were certain people who wouldn’t be comfortable visiting the GP practice.

This worked well as it encouraged people to bring along friends and relatives so positive messages about wellness rather than illness were delivered to a wider group in an environment where they felt safe.

We asked for people’s views on how they were coping with long term conditions, offered a medical assessment and a medication review as well as a holistic therapist.

Our aim was to spread the message about wellness to the right people. We could have put up posters or sent tweets – but how many of those would’ve worked for this very hard to reach potentially isolated, proportion of the population? This way we knew the people we had invited were exactly those people who were struggling.

I’m going to describe three new key interventions which we’ve put in place since:

Firstly, we took 12-15 referrals from the peer support event to our GP practice community connector or social prescriber who will organise visits, spend time with them and listen to their issues.

We expect some of these might be about housing, family, finance, equipment, isolation or many of the other social determinants of health that often exacerbate long term conditions and lead to hospital admission.

Once the connector has developed a coproduced, personalised plan we’ll have helped increase their confidence and self-care options and linked them with third sector groups.

GPs like me don’t have the skills, contact or time to help in this way but community connectors offer a real ‘hand-holding model’ – we’re not just sign posting people to services or support, but working and being with each person until they’re confident.

A second new intervention is working more closely with our community falls car response team which visits residents after a simple fall when they don’t need a specific intervention. They carry out a thorough assessment and signpost to other services.

It’s important we’re more proactive in reviewing patients following a simple fall in their homes as falls can cause massive deterioration in quality of life and longer hospital stays and can sometimes be a warning sign leading to more deterioration.

A third intervention is the use of a simple test which can assess the stability gait of residents just by observing them getting out of a chair – we know that relatively simple exercises or small changes to the home environment can massively reduce the risk of falls and fractures, therefore we’ve been running these exercise classes in some care homes.

We’re very proud of the work we’ve been able to do to help these vulnerable and often unseen members of our community who often rely on carers or family to help them in the most basic tasks.

Being able to understand more about our patients’ lives and find for them, not just interventions that help medically but also socially, is an achievement not many GPs can currently claim.

With the spread of PHM techniques now, my vision is that every GP should soon be able to fully connect with their hard to reach groups, and person by person offer them the help they really need.

Dr Yasara Naheed

Dr Yasara Naheed is a GP partner at Thursby Surgery, Burnley, and Clinical Director for Burnley East Primary Care Network. She has practiced at Thursby Surgery since 2004 following her GP training.

Yas has lived in Nelson for over 40 years. Living and working in the area means she has a strong connection and understanding of the needs and challenges facing her patients. She recognises the value and importance of community and community assets and networks and this has influenced both her practice and her development of Population Health Management which she has led for the Burnley East Primary Care Network in partnership with her GP colleagues and other partners.

Prior to this Yas co-led a groundbreaking partnership between the local GP practices, primary schools, police and local youth theatre to help build resilience and confidence for young people. Her particular interests are mental health, women’s health and diabetes. She has also been involved in training of medical students and foundation doctors at the practice. In her spare time she enjoys playing badminton and watching football.

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  1. Dr Kieran Murphy says:

    This is a real practical example of coordination to proactively support vulnerable and hard to reach groups.
    Great work

  2. Lakh Gossal says:

    Great work, Dr Naheed! It shows what excellent opportunities exist when we all get behind and support our GP’s more. The difference this makes to our Patient’s health and well-being is truly apparent.

    • yasara naheed says:

      Thanks Lakh , you and Andrew are both such great assets and wonderful colleagues. Working with you was awesome and the amount of information that BI has is just mind blowing.