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Pulse PCN roundtable: Population health management, part 1



PCN clinical directors and a population health expert joined Pulse PCN editor Victoria Vaughan on Microsoft Teams to discuss how this approach is working in their area

Victoria: Could you start by outlining your current population health projects? 

Dr Jeremy Carter, CD, Herne Bay PCN, Kent 
We’ve been doing this in one guise or another for a long time. For many years we’ve been looking at who we might focus resource on based on prevalence of a disease area, for example using a QOF register. Now, it’s got a different name – population health management

The way I look at it as a CD is this: we’ve got population health management projects at integrated care partnership (ICP) or integrated care system (ICS) level. Those are things the system is looking at that then get directed down to the PCNs. The example in our area is patients that have diabetes, a diagnosis of depression, live in an area of deprivation and have three other comorbidities. So, we look at a specific cohort of patients that have higher need, identify them and put resources around them. 

That dovetails nicely in our PCN because we’re working on an integrated care diabetes project for East Kent, so our PCN is piloting that. We have an integrated care diabetes multidisciplinary service with the practice, community and hospital trust diabetes teams all working collaboratively. 

As a PCN CD, I’m more interested in how we drive the system. We would like to be doing population health management from PCN level. That’s where I think we are on that learning process. Where do you start? Do you identify that from a clinical view in the PCN, do you look at it from a patient perspective, with your patient participation group (PPG), for example? Do you look at it purely from a data point of view? There are obviously all the different data sources we can access from Public Health through to the medical side of things, through IT tools. 

So we’ve looked at that, and we, as a PCN, are going to take a hybrid view with all of that. This is where [our work with] alcohol [misuse] came in. The public health data for our PCN show where we sit as an outlier. But is it something the patients think is important? 

And, really importantly, [there is the] question of funding as you want it to be achievable and deliverable. You could look at integrating with community support, with alcohol support services, with the police, with A&E services, third sector support. There are lots of things you could do, but where’s the funding? 

The answer is ‘you’ve got ARRS roles’, and that’s true but they are already doing things. If we are going to start doing more work, how do we square that circle? That’s where we are.

Dr Jenny Darkwah, CD, Shoreditch Park and City PCN, north-east London
I’m approaching this from three angles. In my CCG role we have been doing this for a long time. When we started looking at sickle cell anaemia as a population who had severe illnesses, we set up a board with consultants, A&E staff, patients and voluntary workers, to identify the needs for that population. Over the last few years we’ve been able to get GPs involved in the care of these patients, because quite often they had gone into hospital for their care. We’ve set up pathways so that GPs are able to share in the care of some of these patients. I think that’s worked quite well for a set population. 

In my CD role, we sat together as a network and looked at what we felt as GPs was needed. Some issues came up – the isolated male was one of them, a hidden population that doesn’t come into the statistics. We set up a way of reaching those men who never present. They could be sitting at home with their diabetes or their hypertension. We’ve used our social prescriber to set up an isolated male group – a drop in service where they can have a chat about male issues. What we’re hoping to do, in the network, is link that to our health inequalities lead.

We then decided to seek a patient’s perspective on what we actually needed and what the patients wanted from us. So we enlisted Health Watch and set up a survey of about 1,500 patients. From that, we have set up focus groups. We still discuss the document that came out of the Health Watch survey and are using it to inform what we do next. 

One innovation that came out of the survey was a smear clinic for women who were working. We have a young population who are working in the city and quite often couldn’t get to the practice. We’ve used nurses to set up extended access smear clinics for the network. 

The other thing that has come out of the survey is the issue of childhood obesity and a drop in take-up of childhood immunisations. That’s also been formed from public health data and we’ve got
a population health hub that looks at the data across the city and Hackney. We’re in discussions with child and adolescent mental health services (CAMHS), voluntary sectors and schools, to work out together how we tackle childhood obesity. We recognise tackling it should come from the top, with things like adverts. But maybe we can also set up small groups where we teach healthy eating, healthy cooking and get families eating together.

The other thing that helped in bringing services together was looking at our homeless population. When we had the recent displacement of refugees they were brought into a couple of the hotels in my network, so we worked with the councils, MPs, mental health services, language translation services, and it brought everybody together, just having those meetings, to ensure that these people were able to access services in a way that they would understand. Those are some of the projects that we’ve been looking at at a network level. 

Also there were bigger projects on long-term conditions that came down from integrated care boards (ICBs). I think those are things we have been doing for a long time in general practice. They are more established; it’s a way of making sure we are working in a way that is beneficial for patients.

Victoria That’s a great overview of how it is working in Herne Bay and Hackney. Andi, can you discuss what the thinking is at NHS England level and at the analytics level? 

Andi Orlowski, Director of the Health Economic Unit, Lancashire, and senior adviser to NHS England on population health 
I think Jeremy and Jenny were downplaying how advanced they are with health management. Working with the patients, the pragmatic approach to finding what counts in their population and then coming up with the alcohol programme [for example], is exactly one of the actions we would expect to see. No one understands the populations better. 

Jenny [gives a] wonderful example of what we talk about with pop health analytics – the people who are well today who may be sick tomorrow, the populations that are missing from the data, these 45-year-old men who haven’t seen their GP for 20 years because they think ‘I’ll get over it, I’ll be fine’. It’s a sophisticated type of analysis, this whole-population approach, understanding those ‘well’ people today. They may not be well. 

Of course making sure the funding is there for bigger and wider projects [is a key issue]. 

So [we ask] ‘can we have a catch-up,’ and we find [a patient] is double their previous weight, is drinking too much and smoking. We [had them down] as fine because of the last interaction [with them]. 

Working together is the real challenge for PCNs. How do they integrate? Population health management only really works if we deal with wider determinants, great big things, but act [on them] locally. Having PCNs that are already linked to the local authority, as well as the ICS, [gives us] this system view. 

We might concentrate on the same five things that come from joint strategic needs assessments. They all tend to be the same things in different orders. So it will be obesity, COPD, cardiovascular disease, depression and anxiety and one other health issue depending on your area. 

That system level is pushed down to say ‘Where is the greater variation on your patch and what would your population best respond to?’ How do those populations [in deprived areas] access the care? How do you change big things like education, green spaces, pollution, jobs, those kind of things that are beyond our PCN’s direct remit, but are intimately involved with. One other thing that’s super-exciting is the fact that Jeremy and Jenny are doing all of the population health analytics themselves. There’s clearly a lot of capability already in PCNs. How can we fund them, or resource that better for them to do the work?

Victoria What kind of data are you able to provide to PCNs or is it up to them to work it out for themselves? 

Andi NHS England has a number of tools available through the National Commissioning Data Repository, and there are wonderful tools like Fingertips and others. But, of course [because of information governance rules] we don’t have access to that granular primary care data which is absolute gold dust compared with [data from] the secondary user services, acute hospital data. 

Now we are trying to talk about whole populations, we need to have even more than primary care and secondary care [data], we need local authority data. 

For instance, who is on the assisted bin register? If they need help getting their bin to the kerb, they may be isolated because they are too frail to get to it [themselves] and don’t have a friend to [help]. 

There’s loads of additional data available, [but] systems, even the ICS, doesn’t have access to [it]. What [we can get] is the tools, or additional analytical resource. 

But it’s also difficult for PCNs to link their data to all these additional data sets [and] become more powerful. So what NHS England has provided, and can provide, is analytical approaches and tools but without the data we are still relying on people doing their own work. It’s wonderful to see that work is being done. 

Click here to read Pulse PCN’s Leading Questions interview with Andi Orlowski about population health management