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1 - 2 October 2019

ExCeL London

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Uk Health Show

Four leading healthcare shows under one roof

25 - 26 September 2018
ExCeL London

A speaker interview with keynote speaker Dr Jim O’Donnell

Dr Jim O’Donnell is a G.P. & clinical lead for Slough, a partner at Farnham Road Surgery in Slough since 2001.

  1. You have been working on using data management and population health analytics to identify those most at risk of hospital admission. How did this project come about and without giving away too much detail, how are you going about doing this?

In Slough as part of the Prime Minister’s Challenge Fund in 2014, we significantly increased access to GP appointments in the evenings and at weekends. We were awarded the funding in April and by July we were providing bookable GP appointments seven days a week for the first time in the UK, with appointments available on Saturday and Sunday mornings and afternoons, as well as to 8pm on weekdays. Cohesion between practices and patients was central to our success in putting this into practice.

However within the first few months we were not achieving all of our short-term objectives. The number of A&E attendances were not really falling - the main point of the pilot. (They are falling now, in 2018, but this takes a few years to achieve; to see the effects of building trust with our residents.) So in December 2014 we decided to try something new – we focused instead on our patients with the highest risk of unplanned admissions to hospital. We reasoned that if we could identify these patients, we could increase our provision of regular one-to-one care to them, and so reduce then chances of them needing hospital admission.


The first challenge was case finding – how could we do this efficiently and effectively? We worked with our local commissioning support unit (CSU) on this, We had a population of 144,000 but those with multiple, complex needs make up only 5% of the population and there were not good methods of finding these records. The CSU came up with the Johns Hopkins Adjusted Clinical Group (ACG) tool, which allowed us to identify precisely the patients we needed to focus on, and is still by far the best tool available today. Frailty doesn’t really cut it by comparison, though many think it does, and are destined to be disappointed in their belief.


So we found that by focusing on the 5% with more than 5 co-morbidities, seeing them every three weeks with the same GP and team, we could reduce their admission rates by one third, and achieve similar reductions in A&E visits and Out-Patient First Attendances in this cohort. Our PMCF project was a co-design between patients and GP practices with both involved in making decisions. We’d asked ourselves the question: what does good look like in General Practice? We came up with the access element, and also 10 additional project ideas from our residents, which we implemented, along with our focus on those with complex co-morbidities, learning how best to provide them with continuity of care.

  1. What this has meant for the CCG and the patient population it serves?

We ended up being able to reduce hospital activity in this patient cohort, four months after we started this Complex Case Management programme we saw a 35-38% drop in non-elective admissions, and a 30% decrease in outpatient first attendances and in A&E attendanaces.

The idea that GPs were prepared to deliver this was great, and it was great to get patients on board and working together. We provided an additional 48,000 appointments - an 8% increase per year. We were able to achieve patient participation at locality level and immense dedication by our local GPs. We were then able to put an early emphasis on population health and look at the health inequalities in our population and at some of the reasons for these. For example, through this were able to see that the years of “healthy life” for a significant section of our population was not increasing.

This work ties in with one of the key priorities for the Frimley Health & Care Integrated Care System (ICS) to decrease health inequalities so this population health management work enables us to find out what works for our population.

  1. The Slough Locality of the NHS East Berkshire CCG recently won the 2018 Starfield Award for its work in the area of Complex Case Managment. What do you think has been the key to making this work so successful?

    Firstly, the fact that we have been able to build cohesion locally, whilst being able to also evoke interest from practices and GPs to be the best they can be, has been a large part of this success. Secondly, I would say it has to be the recognition of the value of patients and residents in making this happen. We’ve collectively been able to build areas of trust and real delivery to make this work.


  1. You’ll be kindly sharing more about this as part of a keynote presentation and panel on the Commissioning for the Future main stage at the show this year. What is the one message you would like visitors to take away from your session?

Originally, this programme was rather GP centric. However now, we have multi-disciplinary general practice teams involved, along with considerable technology We work closely with a range of professionals including paramedics, physiotherapists, clinical pharmacists, nurses and health coaches to name a few - so it cannot be done by GPs alone. It’s also about technology, which has a critical and increasing role to play in making it sustainable. We are also reaching out to DWP and the fabulous voluntary sector locally, inviting them in.


  1. As the NHS celebrates its 70th birthday this year, what would you say needs to happen to ensure it continues to deliver the best possible care for another 70+ years?

    We need to look at what the challenges across the NHS are. We need to ensure we are able to deliver care so that the NHS works for everyone, in a way that is affordable and at scale to be sustainable. To do this, we should focus on reducing poverty as a key priority, as people on lower incomes suffer poorer health outcomes. Tackling the wider social determinants of poor health outcomes is vital in reducing the numbers of complex case residents of the future. We need to involve health education in schools and in society too – these all play a part in self-care. Finally we also need to focus some attention on the use of over-the-counter medications to relieve symptoms and make the most of the digital sources of information available – information about health and about locally available health and care services. Finally we need to see real transfers of resource across to the social care sector, to where more can be achieved more efficiently than anywhere else in the system. That’s why ICSs are such a good idea.

  2. What are you most looking forward to about the UK Health Show 2018?

    I’m most looking forward to connecting with colleagues and sharing the richness and fusion of ideas and experiences. Even though we are a CCG that has been rated as outstanding, and we are doing a good job, we still have gaps and room for improvement, so it’s a great opportunity to find more solutions, see what our colleagues are doing elsewhere.


Dr Jim O’Donnell will be speaking at the UK Health Show to deliver a keynote presentation entitled: ‘Harnessing data potential and population health analytics to inform commissioning decisions’.

Join us at the show on the 25-26 September to find out more.

This interview conducted by Natasha Smith, Senior Programme Manager, UK Health Show

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