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GPs to provide ‘targeted’ support for frequent attenders, recommends NHSE winter plan

GPs to provide ‘targeted’ support for frequent attenders, recommends NHSE winter plan

PCNs and commissioners should ‘consider’ implementing ‘targeted proactive’ support for patients who are frequent attenders, NHS England’s new winter plan has said.

The new ‘winter resilience plans’, published yesterday evening, said this comes ahead of what is expected to be a ‘very challenging winter’.

In a letter sent to all GP practices and PCN clinical directors, NHS England said that all local commissioners should ‘consider targeted, proactive support for people who have a high probability of emergency admission, sometimes called high-frequency users’.

It said this follows work identifying that around 600 people in one area representing 1% of the population accounted for 1,925 ED attendances and 54,000 GP encounters over a 12-month period. 

Accompanying guidance on the frequent attenders service said it would allow PCNs to ‘reduce unplanned admissions’ while at the same time ‘reducing reliance’ on primary care.

It set out that lists of frequent attenders and those ‘at higher risk of hospital admissions due to psychosocial needs’ should be generated at PCN or ICS level and these patients targeted with ‘proactive’ interventions – delivered by a multidisciplinary team.

The guidance said: ‘These are patients who use services more frequently than usual, including A&E attendances or unplanned hospital admissions and may be identified as being vulnerable, where lifestyle, behavioural or social risk factors are impacting on primary and secondary care service usage. 

‘Through the offer of proactive, personalised care, and in particular maximising the support offered through social prescribing link workers, health and wellbeing coaches, and care coordinators, they can be supported to uncover and address psychosocial support needs, improve their symptom and condition management, and to access a broader range of support options in their communities, resulting in reduced unscheduled use of primary and emergency care.’

It said that if the issues identified are ‘significant clinical or pharmaceutical risk factors’ this caseload would be managed by PCN or practice staff, including individual GPs. 

But it added that ‘consideration’ should be ‘given to existing caseloads and capacity of the workforce’.

Patients with clinical risk factors should then be invited to have a ‘conversation’ with a ‘clinician’ and those with non-clinical psychosocial risk factors directed to care coordinators or other similar staff, then referred to ‘relevant interventions and/or the development of personalised care and support plans’, the guidance said.

This will be followed by ‘regular check-ins’ as part of a ‘rolling programme’, it added.

The guidance said: ‘Cohort identification will need to be refreshed at regular intervals to ensure a rolling programme of support as cases are closed and/or workforce capacity increases or decreases’. 

A case study on the service provided in the guidance described 30 minutes of GP time per week for a 5,000-patient practice.

The guidance also said:

  • PCNs and ICBs should ‘plan for additional recruitment via ARRS and/or System Development Funding (SDF) for primary care to strengthen their capacity to meet the needs of different patient groups’
  • FIT testing in the lower GI pathway, including for patients on endoscopy waiting lists, and teledermatology in the suspected skin cancer pathway should be implemented as a ‘priority’
  • Local commissioners should ‘invest in mental health’ in primary care
  • NHS England is ‘extending’ its workforce support, including by re-launching the NHS reserve campaign and providing targeted support teams for regions in ‘difficulty’
  • Local commissioners should set up ‘system control centres’ at ICB level by 1 December to monitor pressures, including by monitoring primary care demand data and how many FTE GPs are absent on any one day

Meanwhile, NHS England’s primary care chief last week confirmed that there will be ‘no additional’ winter funding to support GPs over the next few months amid a ‘tight’ financial situation.

And a major review has found no consistent evidence that social prescribing improves social support or physical function, or reduces the use of primary care services.

NHS England guidance on ‘targeted proactive support’ for frequent attenders

Step 1: Cohort identification using risk stratification approach 

Using population health management data and risk stratification tools (including the health inequalities dashboard), identify a cohort of patients at highest risk of unplanned admissions, where psychosocial and condition management issues are key factors in admissions, who would benefit from a proactive offer of personalised care to help them increase their knowledge, skills and confidence to manage their health and wellbeing. It is up to local areas to decide which cohorts they wish to focus on, but potential inclusion criteria are set out below or may draw from the High-Intensity Use programme

Potential inclusion criteria: 

  • Patients who have had 2+ unplanned admissions AND been prescribed 10+ medications in the last 12 months AND where professional judgement has identified individuals requiring additional support that may be provided through a SPLW, HWBC or CC in addition to a registered health professional or partners such as pharmacies, VCSE services etc. 
  • Further validation via MDT professional judgement of risk of admission based on additional significant risk factors e.g. age >75, frequent 999 or 111 contacts, and/or multiple LTCs. In addition, anyone identified to be clinically of concern by the discharge liaison team, the practice team, the district nursing team, a community hospital ward doctor, a discharge summary review, through recent contact, or by ambulance or out-of-hours contacts and include carers. 

The Process of cohort identification could include:

  • Application of risk stratification tools to search patient records and identify individuals who meet the inclusion criteria
  • Review of existing disease registers held by practices
  • Proactive searches by acute services to identify patients who make frequent use of services or where reasons for attendance are recorded as non-clinical factors
  • Segmentation based on clinical and psychosocial factors
  • Reviews of patient discharge letters
  • Local intelligence and/or referrals from local partners e.g. pharmacies, social services, voluntary and community services 
  • Referrals from other Winter Pressure programmes. 

Step 2: Allocation of caseloads 

MDT meetings can be used to review the identified list of patients to ensure the appropriate clinician or professional is allocated to each case. This will take into consideration the clinical and non-clinical risk factors for each individual. Consideration also needs to be given to existing caseloads and capacity of the workforce. 

  • For those with significant psychosocial risk factors, caseloads may be allocated provisionally to care coordinators, social prescribing link workers, or health and wellbeing coaches. 
  • For those with significant clinical or pharmaceutical risk factors, caseloads may be managed by a GP, nurse, pharmacist, advanced nurse practitioner, or physician associate.

Step 3: Proactively contacting patients to invite them to discuss their needs 

Patients will be invited to have a ‘What Matters to Me’ conversation about the issues they are experiencing and what type of support might be most beneficial to them, in order to more proactively manage their health and wellbeing. For those patients with clinical risk factors, this conversation will be facilitated by an appropriate clinician, through proactive personalised care and for those with non-clinical, psychosocial risk factors, care coordinators (or other personalised care roles) will facilitate the conversation. Through shared decision making, referrals to relevant interventions, and/or the development of personalised care and support plans, the patient can be directed to the appropriate support. 

Step 4: Regular check-in points

Following the initial ‘What Matters to Me’ conversation, and any subsequent interventions, there should be a period of check-ins with the patient to check how they are doing with making any changes, and whether there have been any issues in terms of access or the suitability of interventions. This may result in changes to personalised care and support plans, alternative referrals, or assistance with making contact with services. These check-ins can be initiated by care coordinators or other roles within the team. 

Step 5: Review and refresh caseload

Following conversations with the appropriate clinician or professional, and on completion of interventions, patients can be discretely discharged or stepped down to relevant community support, but with the potential for re-entry to the list should a change in circumstance occur. Cohort identification will need to be refreshed at regular intervals to ensure a rolling programme of support as cases are closed and/or workforce capacity increases or decreases. 

 


          

READERS' COMMENTS [16]

Please note, only GPs are permitted to add comments to articles

Not on your Nelly 19 October, 2022 3:55 pm

Ha Ha . No funding. not in the contract. not going to happen. NHSE to sort.

Darren Tymens 19 October, 2022 4:04 pm

Wow, there’s a *lot* of clinical and organisational work involved in that specification – but absolutely no funding, and it’s not contractual.
Plus, does anyone have any spare capacity to take it on?
PCN CDs, please just don’t try to muddle through it and pretend it can be delivered. Just say no and let NHSE face the reality of their longterm general practice strategy.

Turn out The Lights 19 October, 2022 4:25 pm

No payee, No workee.

David Jarvis 19 October, 2022 4:41 pm

What is the plan reinstate Shipman?

Paul Attwood 19 October, 2022 4:58 pm

Yawn. Way back when (early 1980s) I joined a small practice and the area had a good GP Society which met regularly. One of the seniors took me aside and said that it was ever true that 10% of the patients created 90% of the work. I was told it would be inadvisable to “lose” those frequent fliers (thereby reduce my workload) as it would become known very quickly by the others who would respond in a similar manner thereby the shit would be stirred in the community to everyone’s disadvantage. I agreed and got on with it. I got to know most of my ‘Free at the Point of Abusers’ very well.

Now there is no slack and less tolerance in the system for these people. There is no cure other than charging money per contact. That would be enough for most I think. Zero funding and “Follow these guidelines” are doomed to fail.

Patrufini Duffy 19 October, 2022 5:05 pm

Sums up this country – more bullet points. Zero listening. Zero clue.

Mike Pearce 19 October, 2022 5:13 pm

30 mins of GP time per week to do all that and what about setting the process up. It is a little spooky that a rough calculation for my practice for my share of the 37m equals about that amount of GP time……….. weired that. I. ove it when a case study adds up. My spidey sense and 20 yrs of experience says something else about the amount of time. Nice to know we are so valued.

Patrufini Duffy 19 October, 2022 5:25 pm

I don’t think the NHSE likes the phrase : “Please go to A+E – you’re unwell”.

They want you to say “I’m gonna fob you off for the sake of managers and tell you that you’ll be ok ..hold on a few days, without any tests”.

Scandal.

Marcus (Max) Hatch 19 October, 2022 5:27 pm

So, that’s 90 GP attendances per year, vs approx 3 to A&E.

And the answer is MORE input from the GP? What miraculous, previously unheard of service is going to alter this situation? Besides, at that ratio, it would seem to highlight that we are already doing an amazing job of keeping them out of hospital.

Ironically, this demonstrates that getting GP appointments is quite easy, otherwise the numbers should surely be the other way around, no?

David Banner 19 October, 2022 8:03 pm

Stick around in this job long enough and pathetic failed ideas will eventually come round again.
A decade or so ago we would all sit around in MDTs once a month discussing our frequent fliers to tick a box and pick up pocket money for our troubles.
It never made the slightest difference to A&E attendances, was a colossal waste of valuable clinical time, but hey, it was a bit of a skive and we made a few bob.
And now some genius in NHSE (who presumably doesn’t know their history) has had a Eureka moment and decided to saddle us with this time-wasting tripe again, this time pro bono.
Ain’t gonna happen, folks.

Dylan Summers 19 October, 2022 9:16 pm

@David

Exactly. It was called the Unplanned Admissions DES I recall: a case management approach to patients at high risk of emergency admission. It was abandoned because evaluation showed that it increased use of medical resources for this cohort with no evidence of health benefits nor reduction in admissions.

What a surprise (not) to see it’s come back again. A true zombie policy.

David jenkins 21 October, 2022 9:38 am

er……………………..no !

NO EXTRA MONEE……….NO EXTRA WORKEE !

Malcolm Kendrick 22 October, 2022 10:24 am

If you ever wondered why the Soviet Union collapsed.

Gavin Atherton 23 October, 2022 2:05 pm

Ah there is a busy winter coming. Lets block some appointments to do some unfunded reviews for which there is no evidence base. Then the patients who cannot get an appointment due to these reviews taking up our time will either go to ED or we will be expected to see them as extras in our own non existent time.

Mo Sul 23 October, 2022 10:34 pm

ask the story Mps to do the base work… They responsible for social care

Esmat Bhimani 25 October, 2022 9:24 pm

High frequency users and attenders are actually not the ones who need emergency admissions.