What work should we tackle as a PCN?
Simplified segmentation of need.
Practices and Primary Care Networks (PCNs) need to be able to answer the following questions:
· At what level of practice, PCN or Regional Health & Social Care Partnership (such as an ICS) should we be doing what work (Malby 2019)?
· What capability do we have to meet need, and where might we have gaps?
To understand this, and move the conversation away from a circular discussion on, for example, the share of a physiotherapist. We also need a more simplified and pragmatic view that population health data often brings. We need to begin with understanding need.
The following is an example of a modest piece of work designed to stimulate discussions and innovate service models. It does so by using two dominant domains of need and then segmenting them. It is not designed to provide the ultimate scientific truth, but rather it is designed to provide just enough challenge and insight to base improvement decisions on. The domains are:
1. Level of Acuity
2. Social Context Pressure – click here (Downham & Easton 2020) for the implications of social context on primary care
The interplay between Acuity and Social Context Pressure:
It is the interplay between these two domains that define whether a practice, PCN or ICS is best placed to meet the needs of a patient. For example a practice may reasonably be able to meet the needs of someone with medium or even high levels of acuity if the patient’s social context is stable. Conversely, a practice with a traditional model will struggle to help a patient with even low levels of acuity if the patient is under high levels of social context pressure.
The table below details the same sample of high attenders but with the two domains combined, producing a hugely useful segmentation. Note that a different practice might conclude different segments and proportions.
Each segment details the proportion % of the high attending group (n=73) that falls within it.
So what might this table tell us?*
The table shows three main segments – A to C. Their needs should be met in different ways. It is important to consider who is best placed for each segment otherwise the purpose of practices, PCNs and ICS’ become blurred and confused. Professor Malby from LSBU has a great blog that makes this point (Malby 2019). An interesting overall observation of this table is that despite this being a segmentation of the highest attenders in primary care, 24% of sample are low acuity (a self limiting or easily treated condition) and only 8% of the sample are high acuity. So perhaps improving the care of those who attend the most is not a solely clinical question.
A) THE WORK OF THE PRACTICE (≈ 46% of the high attenders): This is the second largest segment. This group spans the full range of medical acuity, but crucially the patients are of stable social context. This work is Linear in nature. It also includes high acuity patients that are stable in context - i.e. they have a network around them. The key ingredients in terms of practice capability to meet these needs would be:
· Regular longer appointments.
· Active management and reduction of unwarranted clinical variation.
· Use of patient activation scores.
· High continuity.
· Group consultations.
· In house mental health provision (for example CBT capability).
· Holistic consultations that are able to hold the relational, biographical and caring aspects of practice in addition to the bio-medical (Pratt 1995).
B) THE WORK OF PRACTICES AS A NETWORK (PCN) (≈ 45%): Patients of low and medium acuity and under pressure in social context. This is where a predominantly bio-medical response will not break the cycle with patients. Practices need more comprehensive capability to help people under social pressure and this can be most effectively done working together at PCN’s level. It is complex problem that requires a networked response. PCN’s should help practices and the broader network to enable:
· Social prescribing and wellbeing coaching.
· High quality MDT working (Malby 2019).
· Complex care nursing (Malby 2019)
· Developing a model of highly skilled generalists, rather than adding on new professionals, services and assessment (reducing handoffs and fragmentation).
· Integrated and holistic assessments.
· Asset based approaches (LSBU 2020) and developing links and assets with the community. This starts with hosting coffee mornings and identifying community champions.
· An asset based approach at PCN level that can evolve into a much more comprehensive network response to helping those struggling with their life context. This may include:
o Network response that includes social care, the community, 3rd sector and schools.
o Development of mental health capability (such as CBT and in house MH nurses).
C) THE WORK OF THE ICS (≈ 8%): This group is the most complex. Note these are not necessarily people who are the most clinically complex, as it is predominantly social context (under pressure or turbulent life context) which is driving the complexity. In fact, in this example, none of these patients are high acuity. Key elements include:
· Robust and integrated response that features primary care, social care and the third sector.
· Response is de-fragmented (radically simplified) and has high levels of relational continuity.
· Work to ‘flip’ the clinical specialist model where possible. So the specialist consults into the patient and generalist (for example the GP who has the relationship with the patient) rather than the generalist referring the patient into a specialist setting.
To conclude:
If the same segmentation is focused on a smaller sample, the top 20, the pattern intensifies. It is the social context pressure that intensifies, rather than the cohort increasing in acuity.
The benefit of beginning to take a simplified segmentation approach is that different parts of the system don’t mix up each other’s work. It is clear what each part of the system should be concentrating on. Without clarity, the natural tendency for the system is to act down. ICS do the work of PCNs. PCNs try to solve the problems that individual practice should. With clarity, we can focus the on the work that each level is best placed to do.
Practices are amazing things. They can support people who are high acuity if the patient is stable in life context (they have a network around them). Some patients do, but many don’t as this analysis shows. It pays for a practice, a PCN and ICS to invest early in models that help with life context pressure. If not, without a capable PCN and ICS model – these patients will be attending A&E on a regular basis.
While this is looking at high attenders, it gives us important learning for other cohorts of patients. The same gaps in capability will feature for other patients – even if they are not high attending (yet). Changes in model will benefit those patients who are under social pressure and under the radar – contributing to PCN priorities such as anticipatory health, tackling health inequalities and COPD prevention.
*It is important to not fall into two particular traps when looking at this.
1. ‘Fixing individual patients’. Countless initiatives have looked at individual high attenders. For the individual this is obviously vital, but this never stops the next patient taking their place. To break the cycle we need to work at service level and break the cycle – stopping people becoming high attending in the first place.
2. Trying to segment ‘neatly’. In a world of specifications, criteria and contract we often try too hard to make segments neat and make a ‘hard’ categorization of patients. But patients are not neat. They might move between different segments at different times of their life, or even within a year.
References:
Downham, N & Easton C (2020),. The Reality of Patient Context in General Practice [online] www.cressbrookltd.co.uk accessed June 2020
LSBU (2019),. Asset Based Health Enquiry, London South Bank University
Malby, R,. (2019) Solving the Problems in Primary Care [online] https://beckymalby.wordpress.com/2020/01/23/solving-the-problems-in-primary-care/ accessed June 2020
Marmott, M (2010) Fair Society, Healthy Lives – Strategic Review of Health Inequalities
Pratt , J,. (1995) A Conflict of Values, CRC Press