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Examine your population health data to reimagine primary care

Learn how population health management (PHM) techniques helped stimulate new ways of supporting patients and track wide-ranging benefits.

By Rupa Joshi | July 2023

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It all started back in 2018. As a longstanding GP and co-clinical director of a primary care network in Berkshire, I was under huge pressure with caseloads. I felt that the traditional 10-minute appointment just wasn’t cutting it.

I didn’t feel like I was connecting properly with patients or getting to the root of what was wrong with them. I wanted to explore if 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 right patient data, which reinforced 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 minor illnesses.
  • Second, across our middle-aged population, we saw a particular peak in appointment demand for people ages 40 to 59. 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. 
  • Third, as we looked at our QOF, IIF and DES indicators and compared ourselves against national averages, we saw significant areas where we could be doing a lot more — asthma, COPD, dementia, diabetes and cancer screening, for example.

But we simply weren't able to do so because we were working flat out in managing the demand for appointments.

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Group consultations to support young families

We asked ourselves what we could do differently. I’d just been at a workshop where someone talked about group consultations as a way to support their practice population. We thought this could be a workable option for our younger population, particularly young families. 

So, that’s where we started. We set up a webinar focusing on health for under 5s that we ran jointly with a health visitor. It was originally a video group clinic that parents logged in to during the height of the pandemic.

We discussed when to see the doctor, how you can treat your child and how the pharmacy can help. There was a huge response to these sessions, and we saw a big difference in the population health data: it significantly reduced the numbers coming in with minor illnesses.

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Group consultations for postnatal care

We developed a similar approach to postnatal care. At the time, our health visitors were working remotely in the community and no NCT groups were running due to social distancing rules. As a result, families couldn't access the usual services they would use.

This had some particularly distressing consequences. There were several cases of shaken babies in our area, with 2 of the 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 contacted a safeguarding nurse, health visitors, a midwife team and mental health practitioners. We also put on our first group consultation. We had 26 families who had given birth within the last 3 months, and we brought them all together.

We talked about the issue and showed a 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 setting up the clinic, there were no more shaken babies in our area. 

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Self-care sessions for knee replacements, asthma and more

The 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 asked the pain clinic consultant to come in and run self-care sessions for those on the waiting lists:

  • This helped patients manage pain and maintain muscle tone ahead of their operation.
  • It also successfully reduced the number of times they came to us.

We organised similar groups for asthma, hypertension, diabetes and long COVID. We involved multiple partners in the process, from respiratory nurses and physiotherapists to personal trainers.

We also used our network’s ARRS staff strategically to help us deliver on all of 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. 

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Creating a patient community

Over time, the benefits of this approach extended far beyond what we originally envisaged. Soon after starting these sessions, I watched our healthcare assistant and 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 patients and know that the group will go on to achieve amazing things together. 

In fact, as these clinics grow and mature, we’ve found that they take on a life of their own, with solutions being created as much by the patients as the clinicians. For example:

  • Parents of 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 patient said 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 accountable to one another 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 see. 

Perhaps most important of all, our patients love it and it works. If you ask them, “Would you rather go into a group or have a one-on-one clinic?” they'll say a one-on-one. But after they've had a group clinic, 90% want another group as a follow-up, not a one-on-one. 

Outcome measures back this up:

  •  In our diabetes video group clinics, we saw an HBa1C reduction of minus 30 across a cohort within 6 months, an incredible result.
  • We also held sessions for a small cohort of parents of children with severe asthma in early autumn to get them ready for the winter.
  • We chose a group that was extremely susceptible and had attended A&E multiple times in previous years.
  • The following year, the number of attendees in that cohort dropped to zero after just one clinic.
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Breaking down silos to bring people together

Looking back, I feel like 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 much from our social prescribing link workers, care coordinators and health and wellbeing coaches, from their deep compassion for patients to the skillful way they help patients 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 helps break down silos between different teams and disciplines. It brings people together around a common purpose: to do the very best for patients.

For me, it also shows population health management at its purest and most powerful — and it’s one of the most worthwhile things I’ve done in my career.

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About Rupa Joshi

Rupa is a longstanding GP and managing partner, co-clinical director of a PCN and deputy chair of the Berkshire West Primary Care Alliance. 

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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.