GP Dan Alton, from Wargrave Surgery in Berkshire West, explains how the Population Health Management Programme led to more personalised care for diabetic patients in South Reading and Wokingham.
Watch a film with patients Steve and Michele who benefitted from the new approach.
Thinking about my New Year’s resolution I couldn’t help but draw some unusual parallels with our work in the health and care service about how we’re going the extra mile to help our local populations.
Unfortunately, many of us start out with great intentions but by January 3rd have forgotten those big ideals already!
What we need is something manageable we know we can and will achieve – and this is where the parallel begins.
The Population Health Management (PHM) Programme has helped us in Berkshire West to find a raft of diabetic patients needing new, tailored care interventions to meet their needs.
Despite our best efforts there are still some people slipping through the net; just like a rash New Year’s Resolution, a one size fits all plan can start with the best of intentions but turn off more people than it helps.
We need ‘personalised care’ as we call it in the health service – but to get to this point we have to do a lot of work first.
In Berkshire West, we were part of the first wave of the NHS England PHM Programme where we got extra support to take time and space to look at what’s really happening in our populations and think about how we can make local services more nuanced and tailored to people’s needs.
The data we’ve used previously has often been organisational – so for example we could see that a patient had attended their GP, A&E or outpatients a certain number of times, or not engaged with follow-up, but didn’t always have a more comprehensive picture. We need to dig a little deeper to design services that truly address our patients’ holistic needs.
So what did we do differently? First of all, we mapped our local skill base and found about 19 analysts who had PHM capabilities, we then worked hard with the data from across organisations to really bring something new and meaningful for discussion with the right clinicians and professionals in our Primary Care Networks.
We ended up with a set of five years’ historic data, linked and costed allowing us to see the activity forecast for if we did nothing and if we made different interventions for different groups of patients. It also showed us patterns of activity and spend and where the main increases will be in future. It became clear that we needed to be much more proactive with our care services for some groups of patients.
We brought a clinical PHM ambassador around the table with managers and analysts – the golden triangle – who were then able to assess the data and suggest different approaches needed for certain groups of patients.
Diabetes for example, we could see was a priority issue for quite a few of our Primary Care Networks, and we could see there was a cohort of diabetic patients who would likely become ill in future due to their diabetes control not being as optimised. It’s important we keep them as well as possible to prevent this degeneration of their health and also the huge expenditure we could incur further down the line.
In Wokingham North PCN, we contacted ten patients in this group identified to discuss their experiences and how their diabetes can be improved. While the population is quite affluent, the ten patients we spoke to reported themes of busyness and simply not being able to find the time to engage properly with their health.
They said they knew all about the need to control their diabetes but their priorities were their jobs, mortgage and paying the bills and the weekday clinics to see the diabetic nurse didn’t fit in with their lives. They also reported feeling slightly patronised by the previous approach to education on their condition which they had encountered and wanted more of a two-way dialogue. Hear more from patients Steve and Michele in our film about this:
We developed a new service, involving group consultations with a lifestyle GP. Read more about that here from Dr Jennifer Singh who led those groups.
Working together at the practice we were able to offer a local solution thanks to Dr Singh and bring those people back to re-engage with their care.
In other practices they came up with other solutions to their problems. For example, in South Reading analysis of people with Type 2 diabetes pinpointed poorer outcomes in the Nepalese community who had a lower uptake of the standard NHS diabetes education offer.
Working with the Nepalese community, a programme has now been created which provides structured education – delivered in Nepalese – for patients who had struggled with the service in English. A specialist nurse – who is Nepalese and understands some of the cultural variants within that community – delivers the programme.
The PHM approach has been invaluable to us reconnecting with those people in our communities who need more than we have historically offered. Technology, data and improved local relationships means now we can act on those insights.
It seems simple to say ‘why not offer people what they really need to help them feel better’ but that will only work if it’s tailored for that person – and like our New Year’s resolutions, is doable and achievable in the long term.