How population data helped us reimagine our primary care services

PHM at its purest and most powerful:

By Rupa Joshi, July 2023

As a longstanding GP and co-clinical director of a Primary Care Network in Berkshire, Rupa Joshi has spearheaded the development of group consultation approaches across her network. In this latest Perspectives blog for Optum UK, she describes how population health management techniques helped to stimulate new ways of supporting patients and track their wide-ranging benefits.

It all started back in 2018. I was under huge pressure with caseloads and felt that the traditional 10-minute appointment just wasn’t cutting it. I didn’t feel I was connecting properly with my patients and wasn’t getting to the root of what was wrong with them. I wanted to explore whether we could do things differently and better. To do so, I realised we needed to understand what was really going on, and confirm the feelings we had about some of the population.

We discovered several things when we examined the data, reinforcing our view of the young population. First, we found we had a lot of young patients and young families coming in, with lots of mental health issues and lots of minor illness. Second, across our middle-aged population, we saw a particular peak in appointment demand for 40 to 59-year-olds: menopause consultations made up a big part of this, but we also had a lot of carers looking after elderly relatives who were very stressed.

And third, as we looked at our QOF, IIF and DES indicators and compared ourselves against national averages, we saw there were some significant areas where we could be doing a lot more – on asthma, COPD, dementia, diabetes and cancer screening, for example. But we were simply not able to do so because we were working flat out in managing the demand for appointments.

Supporting young families

We then asked ourselves what we could do differently. At the time I’d just been on a workshop where somebody was talking about group consultations as a way of supporting their practice population. We thought this could be a viable way of supporting our younger population, and particularly young families.

So that’s where we started. We set up a webinar that we ran jointly with a health visitor focusing on health for under-5s. It was originally a video group clinic that parents logged into during the height of the pandemic. We discussed when to see the doctor, what you can do to self-treat your child, and how the pharmacy can help you. There was a huge response to these sessions, and we saw a big difference in the data: it significantly reduced the numbers coming in with minor illnesses.

Postnatal group consultations

We developed a similar approach to a postnatal care. At the time, our health visitors were working remotely in the community and no NCT groups running due to social distancing rules. Families were therefore being cut adrift from the usual services they would receive, and this had some particularly distressing consequences: I’d become aware that there had been several cases of shaken babies in our locality, with two of infants admitted to ICU as a result. As a parent and a practising clinician, I knew we had to do something.

Within 10 days, we had contacted a safeguarding nurse, health visitors, a midwife team, and mental health practitioners and we put on our first group consultation. We had 26 families who had given birth within the last three months. We brought them all together. We talked about the issue, showed an educational video on crying babies. We explained that if you've checked your baby, they're safe to be left and parents can take a break. The results were immediate: after we established the group clinic, we didn't have any more shaken babies in our area.

Knee replacements

And we found that this group consultation approach worked just as well across other population segments. We were inundated with people waiting for knee replacements, because of the growing waiting lists in the local hospital. We therefore asked the pain clinic consultant to come in and jointly run self-care sessions for people waiting on waiting lists. These helped the patients to manage pain and maintain their muscle tone ahead of their operation, successfully reducing the number of times that were coming to us.

We organised similar groups for asthma, hypertension, diabetes and long COVID. We involved multiple partners in the process, from respiratory nurses to physiotherapists to personal trainers. We also used our network’s ARRS staff strategically to help us deliver this – for example, our social prescribing link workers did our ‘caring for carers’ sessions for us and our care coordinators did all our administration and facilitation for us.

High fives

Over time, the benefits of this approach have extended far beyond what we had originally envisaged. Soon after we started these sessions, I watched our healthcare assistant and our practice nurse walk down the corridor and do a high five together after a diabetes group clinic. It was a simple expression of a feeling we’ve all had when we’ve really made a connection with our patients and know that the group will go away to achieve amazing things together.

And in fact, as they develop and mature, we’ve found that these clinics take on a life of their own, with solutions being created as much by the patients as the clinicians. For example, the parents of the asthmatic children in our clinic created a WhatsApp group that they used to text each other if they weren't sure what to do in different scenarios. In our diabetics group, one of the patients mentioned that they wanted to do the ‘over 50s’ swim session at the local pool but didn’t have anyone to go with. A group of them now go swimming once a week together.

In effect, this becomes so much more than just the provision of a service in a different form. We’re creating a community, a network of people who feel accountability to each other and a real sense of ownership and agency over their health. They’re caring for themselves – and for each other – much more than they ever did before. And that’s such a powerful thing to witness.

Perhaps most important of all, our patients love it – and it works. If you ask a patient, “Would you rather go into a group or have a one-to-one clinic?”, they will say they would rather have a one-to-one. But after they've had a group clinic, 90 per cent of them want to have another group as a follow up rather than have a one-to-one.

The outcome measures back this up. In our diabetes video group clinics, we saw HBa1C reduction of minus 30 across a cohort within six months, which is an incredible result. Similarly, we ran sessions with a small cohort for parents of children with severe asthma in early autumn to get them ready for the winter. We chose a group who were extremely susceptible and had been attending A&E multiple times in previous years. The following year, the number of attendances within that cohort dropped to zero – just from one clinic.

Conclusions

Looking back, I feel I’ve become a better doctor because of these experiences. Group clinics constantly help to challenge your thinking because you're working with and learning from different people all the time.

I’ve learnt so much from our social prescribing link workers, care co-ordinators and health and wellbeing coach: from the deep compassion they show for their patients, to the skilful way that they help them to set their own goals and take control of their own health outcomes. I’ve also gained new perspectives on what patients with chronic pain go through and how I can help them in a more holistic way.

Above all, this process has helped break down silos between different teams and disciplines, bringing people together around a common purpose: to do the very best for our patients. For me, it represents PHM at its purest and most powerful – and one of the most worthwhile things I’ve done in my career.

This article was prepared by Rupa Joshi in a personal capacity. The views, thoughts and opinions expressed by the author of this piece belong to the author and do not purport to represent the views, thoughts and opinions of Optum.