Extra 500 people with complex health issues are supported by MDT thanks to Population Health Management

Case study summary

500 people with complex health problems made almost 450 fewer visits to A&E or stays on a hospital ward thanks to the proactive Population Health Management (PHM) approach.

Note: Some sections of this case study refer to clinical commissioning groups (CCGS). On 1st July 2022, integrated care systems (ICSs) took over statutory commissioning responsibilities in England, and CCGs were closed down.


Buckinghamshire, Oxfordshire and Berkshire West Integrated Care System; Wokingham Integrated Care Partnership, 13 GP practices, 4 Primary Care Networks. They took part in the National PHM Development Programme.

What was the aim?

More than ever, people need care across many different settings. If this isn’t coordinated, it can result in patients’ health declining and multiple appointments with hospitals and GPs.

In Wokingham locality they had a set of complex patients with complex co-morbidities whose care was sometimes disjointed. Despite multiple contacts with different professionals, it was clear that their underlying needs were never truly addressed in a person-centred way.

They were at high risk of unwarranted health outcomes and we wanted to use proactive interventions to help them live well and independently for longer. This project aimed to improve their health and wellbeing and reduce repeated non-elective admissions to A&E secondary care, GP in and out-of-hours service, A&E attendances.

What was the solution?

The hospital support needed by the group of patients in Wokingham dropped dramatically after linked datasets were used by GP teams to define those most in need and a multi-disciplinary team of doctors, matrons, social care, occupational therapists and social prescribers worked together to personalise their care.

They offered enhanced health checks and assessments but also social help including help with shopping, exercise and lifestyle issues.

The data showed a need to focus resources on patients who live alone, have a rising social care need and a medical need; the proactive approach meant they were looking at patients slipping through the net as well as those already known to services.

The linked data used was the local Connected Care platform, incorporating data from primary care, secondary care, mental health and social care, in conjunction with the Insights Population Analytics platform, developed by SCWCSU. This revealed a cohort of patients who could benefit from proactive care, with the following characteristics:

  • A high frailty score as measured by Electronic Frailty Index AND
  • multiple non-elective admissions in the last 12 months, or
  • multiple A&E attendances in the last 12 months or
  • multiple contacts with health services in the last 12 months

566 people with the above combined attributes were discovered to be at higher risk their health deteriorating.

With patients permission they were discussed at the virtual MDT and offered a personalised plan including the optimisation of their medication, a community matron review if appropriate, a social care assessment and support, an OT assessment and support and a community geriatrician review visit, social prescriber support and the links to community groups.

Over 2 years 566 people were supported and there were 176 fewer non-elective admissions and 270 fewer A&E attendances in the six months following intervention compared to the six months before.

What were the challenges?

Clinician engagement was a significant challenge at the beginning of this process. But the benefits of the programme became self-evident as it progressed, which led to further positive engagement from clinicians and other professionals.

Consent and IG issues were complex, meaning clear strategies were needed. A local IG steering group provided their expertise so we could ensure correct procedures were followed.

What were the results?

For the total patient cohort (excluding patients who passed away or moved out of the area), there were 176 fewer non-elective admissions and 270 fewer A&E attendances in the six months following intervention compared to the six months before.

In general, you would expect this cohort to get more complex with time, so it’s a very good result to see so many fewer attendances. Unfortunately, the COVID-19 pandemic meant we have not completed the longer-term evaluations for this cohort as yet, although the MDTs have continued to operate.

What were the learning points?

GP Dr Dan Alton, a GP at Wargrave Surgery in Buckinghamshire, Buckinghamshire Oxfordshire and Berkshire ICS, Population Health Management (PHM) Clinical lead and National PHM Clinical Advisor for NHS England, said: “More than ever, people need care across many different settings and if it’s not coordinated, it can result in patients’ health declining and multiple appointments with hospitals and GPs. We knew we had a big group of people in this situation but we weren’t sure which group to start with.

“Being able to proactively look for people with a defined set of risk factors has helped us to target our resources much more effectively. Our wide and experienced team can then make a plan which will genuinely help the person address the real issues they’re facing whether that’s medical or social.

“The wider determinants of health play such a huge role in patients’ health outcomes and this type of model puts that concept front and centre”.

Guy from Wokingham had chronic diabetes and had two brain aneurysms and two strokes.

He was in and out of hospital every few weeks, but since being under the care of an integrated health and social care team, he has not been admitted to hospital for six months.

A multi-disciplinary team including a social worker, occupational therapist, district nurse, diabetic nurse and housing officer meet with him regularly to address all aspects of his needs. The team arranged for improvements to be made to Guy’s kitchen so he can prepare healthier meals for himself which Guy thinks has been the biggest reason he has stayed out of hospital.

He said: “This is a lot better way of giving me a better outcome and a better lease of life. The whole system works better when everyone is informed and involved. It works like a proper networking system – it’s a lot faster and a lot more informative.”

  • Inclusion: Ensure engagement from all system partners at the very early planning stages. Ensure key stakeholders are included to develop a collaborative approach which helps to address challenges in all organisations.
  • Adaptability: Keep flexible, to adapt processes to local changes. From a general practice perspective, it does not need to be the GP taking part in the MDTs. The skillsets of other professionals, such as paramedics and clinical pharmacists, are equally as relevant.
  • Information governance: Tackle IG issues early and draw on support from your system in terms of IG expertise.
  • Person-centred care: Ensure person-centred care is central to your ethos. Ensure the strategy developed recognises what is truly important to the individual receiving the care, and aims to support this.
  • Efficiency: MDTs can involve short discussions in most cases, with clear actions. Co-ordinators can assist in maintaining this approach, avoiding excessively long discussions, and accepting that professionals’ time is often in short supply. Ensuring discussions are focussed on developing actions is important – an SBAR approach to communication can be helpful in this regard.