In 2015, NHS East Berkshire Clinical Commissioning Group (CCG) launched a six-month pilot in Slough to test a new type of care programme that would help them identify those most at risk of hospital admission.
The project, Population Profiling to Support a New Model of Clinical Delivery, used the adjusted clinical group (ACG) system to identify people at risk of hospital admission by giving GPs access to patient data – including details on how much they use hospital and prescribing services – allowing for the creation of tailored care plans.
Developed by the Johns Hopkins Bloomberg School of Public Health in the US, the ACG system is a computer programme that analyses data and makes it easier for users to make decisions. It has been used in the NHS since 2009.
East Berkshire CCG’s innovative project was chosen as the 2018 winner of the Starfield Award, which celebrates the work of organisations ‘addressing multi-morbidity in patients and populations, reducing disparities in the delivery of primary healthcare, and improving population health’.
Sangeeta Saran, associate director of planned care and Slough operations at NHS East Berkshire CCG, explains how the new care programme has made a difference.
‘Based on our data, we knew that hospital admissions were rising in Slough and that GPs and patients only ask for help when they reach crisis point.
But we didn’t have a system in place that would allow doctors to help patients manage their condition before it became a crisis.
When we tried to understand why some patients end up in hospital far more frequently than others, we found that we weren’t inviting patients for regular reviews in GP practices. Patients would end up accessing care when their condition became critical and generally that meant we had to hospitalise them.
We also knew that GPs don’t always have the capacity to invite patients more frequently and to devise a care plan, because they are overstretched.
Had we not given them dedicated time and resources – such as longer appointments to see patients at risk of admission – it would have proved difficult for them to provide the proactive care that is at the heart of our new model of care.’
‘Clinical input from our GPs was essential to working out which patients we needed to review more frequently. We identified around 550 patients in Slough, including individuals with a combination of cardiovascular disease, diabetes and respiratory diseases.
We launched our new model of care in 2015, initially as a six-month pilot, with all 16 practices in Slough taking part. The pilot was later extended for a year.
After merging with Bracknell and Ascot CCG and Windsor, Ascot and Maidenhead CCG to become NHS East Berkshire CCG in April 2018, we started commissioning this model to the rest of the practices in our area – around 48 practices have now been offered access to this programme.
We are also beginning to commission it across our integrated care system, Frimley Health and Care.
We support the GPs by giving them the funding needed to work more proactively, so they can spend half an hour with patients from our designated group. We asked our GPs to review them regularly (every three weeks in some cases).
Thanks to additional funding we received, practices can release GP time by adopting innovative models – such as employing a clinical pharmacist to do some of on the day work.
Participating practices only need to sign a data sharing arrangement to share their data on an anonymised basis and support risk stratification (the process of assessing how at risk a patient is). In our case, it was the ACG system that allowed us to make predictions of an individual’s health over time.
The system allows GPs to access their patients’ data and see how much they consume in terms of hospital and prescribing resources, which gives them enough information to target care around the patient’s needs.’
‘The biggest challenge was releasing GP time. We designed our model of clinical delivery with our practices and we did not experience barriers for practices wanting to take part in it.
Communication and contact with practices was crucial. We needed to visit our practices and make sure we were all on the same page.
Practice managers were absolutely essential to implementing our model, as they were helping to release the clinical time within the practice.’
‘Over a 12-month period, we managed to divert 18% of the patients within our designated cohort from being admitted to hospital. We will continue to work on our new model of care to extend it to the rest of the population.’
Sangeeta Saran is associate director of planned care and Slough operations at NHS East Berkshire CCG.
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