The Foundry Model

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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.    



2.      What is Population Health Management?

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 ispopulation 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.

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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.

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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.


5.      Re-designing Clinical Capacity Around Patients Needs

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.

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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.