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