Population Health Management Enabling Personalised Care 

RAG, A Practical Solution for Primary Care

Dr Phil Wallek, Clinical Director, Foundry PCN

May 2023

1. Introduction

 

Foundry Healthcare Lewes is a single practice PCN in East Sussex that has been receiving an increasing level of interest due to its innovative population health management approach, in particular:

 

• Segmentation of its registered population;
• Re-engineering the clinical model around urgent on the day access hubs for generally well patients and continuing health care teams for the more complex and frail;
• Embedding a truly multi-disciplinary team approach within primary care;
• Development of a collaborative digital workforce tool to optimise capacity.

 

This document sets out the history of how the Foundry was established from three former Practices, the methodology and tools we developed and deployed in segmenting the population and re-engineering the clinical model, the outcomes to date for patients and the wider system and the opportunities for learning and dissemination of the model across the primary care landscape.    

 

 

Population Health Management (PHM) is a way of working to help frontline teams understand current health and care needs and predict what local people will need in the future.

This means we can tailor better care and support for individuals, design more joined-up and sustainable health and care services and make better use of public resources.

PHM uses historical and current data to understand what factors are driving poor outcomes in different population groups. Local health and care services can then design new proactive models of care which will improve health and wellbeing today as well as in future years’ time. (NHS England)

Data may be used to identify groups of people who are frequent users of accident and emergency departments, to offer preventive interventions that improve health and reduce demand on acute services. One common approach to population health management is ‘population segmentation’. (Kings Fund)

 

3.      Putting Patients at the Heart of a Vision for Change

 

In 2017, three GP practices in Lewes started working together with the prospect of moving into a new building.  We were considering if we should do this as 3 separate practices or as one larger organisation. Looking for examples of good practice, we joined the NAPC Primary Care Home programme after a presentation by James Kingsland at a CCG learning event.

The Primary Care home model seemed to fit with the size of our population and a common ethos of working together to value all members of the primary care team. We gained inspiration by visiting Bromley by Bow in South London and Granta in Cambridge which prompted discussions and an appetite to understand our population and current patient pathways to ensure we could focus our resource on those most in need.

We stimulated a case for change at the practices with a series of 4 immersion events. We brought together all of the practice staff over 4 half days and split into mixed teams of clinicians and non-clinicians to look at 6 randomly chosen patients. We looked at their GP records, social care records and hospital records before spending time speaking to the patients in person. The process highlighted the difficulties faced by different types of patients trying to access care and navigate the system. Hearing patients experiences from a new perspective created motivation, engaging all staff in improving care for our patients which has continued ever since.

4.      Understanding Patients’ Needs: Segmenting the Registered Population with RAG

 

We realised that systematically identifying and recording the differential needs of patients was key to adapting pathways accordingly and offering the very best personalised care. We started by using the electronic frailty index which combined a number of read codes to identify high need patients but found it often over-estimated patients' frailty and so needed to go back to the GP’s who knew the patients to check if they were really frail.

We looked at further combinations of read codes with support from the commissioning support unit but again found increasingly complex combinations without creating useable information. In addition to the frailty groups, we also recognised the significance of frequent attenders in General Practice who may not have a come up in the read code-based searches but used a significant proportion of General Practice resource because of their health behaviours.

The key factor that seemed to link all groups of high need or vulnerable patients was an understanding that the clinicians felt they required more continuity. This also matched the patient’s wishes of increased continuity and led us to consider a clinician defined criteria of complexity of care.

Steve Laitner at NAPC had created a model defining 3 groups, generally well, ongoing conditions and complex needs. This opened up the idea that those patients who were generally well were less interested in continuity and were happy to see any competent clinician.

We took the model and adapted this to form Green, Amber and Red patient groups. Initially we coded all of our high need and complex patients by creating a basic template for GP’s to follow but left them to define exactly which patients should be red. This included Frail and nursing home patients, palliative patients and complex mental health or substance misuse patients but could also include patients with social issues.

The red patients were relatively easy to identify and code as they were well known by the Primary Care team. The rest of the patients were left by default as green but as patients attended for appointments those with ongoing conditions needing continuity were identified and then coded amber using a pop up template at the end of each consultation.

Asking the clinician after each consultation if they should remain in the current group created a live and reactive record of all patients in the practice which identifies the patient as Red, Amber or Green using a colour dot in the patient demographics box in the clinical record which is visible to any staff member who is accessing the clinical record. It initially took around 6 months to generate an accurate code for all patients.

The live RAG system has subsequently been used to design different care pathways. A key factor in the engagement of clinicians to use the system to enable change is their interaction with the coding. The clinician is the person creating the code which also creates an agreement to acknowledge a greater degree of continuity and an accountability for that continuity. Accountability helps create clear patient pathways creating a model for patient navigation.

The initial hypotheses was that identifying the patients most in need of continuity would help GPs to provide better care by trying to give more access to their usual GP or small group of GPs for both reactive and proactive care.

 

As the Eleventh National GP Worklife 2021 survey suggests, average GP working days are 10-12 hours long with the average working week being 40 hours with most GP’s working 3.5 to 4.5 days but with many working less. Many GP’s also take on additional leadership roles or specialist clinical roles such as diabetes care, dermatology, sexual health or minor surgery. Annual leave and sickness also combine to mean that individual GPs are not available 5 days a week to respond to reactive care.

GP practices have grown in size as practices have merged which has enabled groups of GPs to work together to respond to patient demand, but larger numbers of GP’s reduce continuity. We hoped to improve continuity by grouping the GP’s together into small continuing care teams to create the smallest number that could provide continuity across the week, we soon realised though that this did not foster team working as, by definition, teams of people designed to provide cover across the whole week rarely crossed over with each other. We recognised the need for two continuing care teams working together in a practice which enables effective communication and team working with a practice huddle every day at 12:45pm to socialise and discuss complex current patient issues.

The concept of a usual GP who is part of a continuing care team which in turn is part of a practice team has subsequently formed the basis of the design of the our GP teams to provide reactive and proactive care for the red and amber patients.

Once we had coded the patients we found surprising the number of patients whom were generally well and the number of appointments that we provided for this group. We audited a full week of 1880 appointments across the three practice sites and found that 70% of the patients were generally well who utilised 50% of the total appointments of GP’s and our paramedic. We also created an understanding of the priority of patient need broken down into reactive and proactive care.

 

After understanding this mix of patients and appointment utilisation we set about reorganising the GP teams to create a Green team of GP’s.

The GP’s seeing the Green patients were initially located at their GP practice site, but it was when we co-located the GPs seeing Green patients to a single site that realised larger benefits. This created a team working environment where the GP’s sat next to each other triaging and sharing clinical rooms to see those who needed a face-to-face appointment.

In 2022 the Green team moved to be co-located with the Urgent Treatment centre in Lewes. This enabled us to work in partnership with Urgent Care Practitioners on site, providing medical supervision whilst they provide capacity to see the Green Patients.

6.      The Benefits of a Population Health Approach

The segmentation of the patients into RAG was intended to improve continuity of GPs in a larger organisation, it has however provided a lot more than anticipated by creating a model that supports patient navigation and care pathways.

The knowledge of whether a patient is in the green, amber or red group when they contact the practice immediately enhances the navigation provided by a receptionist. Red and amber patients can be given preference to usual GP team access but a greater and unexpected benefit is how patients can be directed to other roles.

Green patients more often present with single new problems that can be dealt with by additional roles such as Paramedics or First Contact Physiotherapy Practitioners. Red and amber patients are directed to a usual team GP for medical issues with a longer appointment time as they are more likely to have multiple ongoing issues that need more time to manage, and a GP is more likely to be able to complete their care needs and risk manage complex scenarios. Complex issues dealt with by less experienced clinicians often create failure in the system as patients represent for additional input and utilise more appointments.

This has been demonstrated by a reduction in the number of avoidable appointments. National data suggests this could be as high as 27%, The Foundry was found to be 7% further reduced to 4.5% after further training and adaption of care pathways.

Red and amber complex patients also benefit from input from non-clinical roles focusing on social and care needs. Care coordination and social prescribing being targeted to specific groups such as nursing home patients, dementia patients and palliative care patients.

The targeted use of additional roles has reduced the percentage of appointments used by the top 5% of high use patients from to 30% in comparison to national comparison of 40%.

Perhaps an even greater benefit has been the creation of a common vision of the future for primary care.  Non-GP roles both clinical and non-clinical have been able to offer care and support to the groups of patients that are most likely to benefit from their help. Community staff have been able to work effectively creating a unified vision of how integrated care teams can work with GPs in continuing care teams and the Green Hub.

The other benefits we have seen are:

 

7.      The Impact of Covid

 

When covid arrived, we were faced with a challenge of whether to continue the development of a RAG model. We soon realised that the model immediately showed its benefit supporting the team to reorganise care quickly and efficiently, identify our patients who were most in need, focusing support and then providing vaccinations in priority using RAG rating.

 

 

8.      The Challenges of Organising a Complex System

 

The town of Lewes was a perfect place to seed the development of a new model of care. It is geographically enclosed with a population of 28,500 and had 3 GP practices that were on speaking terms. The journey of change however was not smooth and has taken 5 years. With no blueprint to follow many mistakes were made along the way as new ideas were tried out.

Creating meaningful data has been key to enabling the transformation. Segmentation of the patients produced a new data set that helped to demonstrate to staff the benefits of making change. Developing multidisciplinary groups to work together on patient pathways has promoted change in small cycles. Clinical and non-clinical staff have developed their ideas of how the system can work better and helped to implement change with leadership and management support from the Foundry management team.

These organisation development teams have also enabled outside organisations to join to improve integration across providers. Staff from the community trust, mental health trust and voluntary organisations have all come together to create shared care pathways.

 

Key to transformation was using the RAG model to understand the whole system and create a workforce and financial model. On multiple spreadsheets ideas were created of how to understand demand and capacity for the different patient groups by analysing appointment utilisation and then use this data to inform workforce planning and recruitment. Using this method allows demand and capacity planning, workforce and financial modelling a year in advance creating a sustainable model with financial stability and control which in turn encourages further development.

As the complexity of the system grew, over 120 staff, more than 20 different staff types across 5 sites, the capability to use spreadsheets to plan became unmanageable. Existing e-rostering systems, one of which was trialled for 3 months, were not able to manage the complexity and did not offer the feedback and learning needed to continue to evolve.

GP Networks is a company that had been running a locum booking service for over 15 years in Sussex. It had evolved to create a flexible workforce platform that was being used for Extended Hours Care in Brighton and was quickly scaled to support the covid vaccination hubs in Brighton. Recognising a common goal for digital Transformation of primary care Foundry Partnered with GP Networks and spent the next 2 years creating Tempo a collaborative workforce platform.

Tempo links workforce with financial and clinical data to produce a learning system able to inform complex pathway redesign. Tempo has the benefit of being built on an existing flexible workforce pool so as each new organisation joins the possibilities of realising the benefits of integrated working between organisations increases and the pool of flexible workers and volunteers in the network grows.

The RAG system is also supporting the implementation of the next generation of phone and online consulting systems in the Foundry with the capabilities to utilise the benefits of the RAG model creating new digital pathways directing patients automatically to the most appropriate outcome.

 

10.  Cultural Change

 

The biggest hurdle in transformation was recognising the cultural change and managing this compassionately. GP practices have evolved from single handed practices to larger practices with their own culture and identity. Merging into a larger organisation created gains but at the same time a loss of the original practices which we have tried hard to hold onto by continuing with the practice teams.

Visiting other practices to see good examples of working at scale was key to creating a vision. A great deal of learning about system transformation was needed including understanding the anthropological basis of why it feels different in a larger organisation. Dunbar described how 150 people is the maximum number to maintain meaningful relationships in an organisation and helps to explain why the size of organisation we became made sense with 120 staff. It also helped to shape our understanding of the need to consciously maintain smaller teams whilst creating shared processes and governance.

A significant cultural change has been achieved but the amount of change has been challenging, the RAG model however created a unified vision which all staff could follow. Staff and GP partners now feel it has been worthwhile creating a new positive future with even the most resistant of staff being great supporters of the Foundry model.

11.  Disseminating the Model - Learning for Other Organisations

 

Every Primary Care organisation and system is unique with geographical and cultural differences. Practices, PCN’s, federations UTC’s and Integrated Care Systems of all sizes and configurations creating complexity.

Distributing leadership to practices and neighbourhoods with local knowledge is key to the sustainability and transformation of primary care. Good examples have been shown of the importance of moving away from a fixed hierarchy of command and control and devolving responsibility to smaller teams able to respond to local needs.

Source: McChrystal,Stanley. “Team of Teams – New Rules of Engagement For A Complex World, p129

Other care systems have already experimented with RAG rating of patients and have independently come up with remarkably similar patterns of the split of patient populations. Many practices already have less formal processes for identifying high need patients but unifying the approach to patient segmentation could create a way for Primary Care Organisations of any shape or size to collaborate as a system whilst retaining autonomy without the need to merge.

Tempo can enable organisations to share staff whilst creating the business intelligence to manage finances and create data insights to support integrated working and system redesign.

The new building Foundry hoped to move into that started our journey has yet to arrive but what we have realised is that in any location enabling the right patient to see the right clinician at the right time can improve patient outcomes and staff satisfaction at the same time as saving money for practices and the wider health and care system.