Yesterday, The Kings Fund hosted an online event about transforming healthcare at scale. The theme was to explore the advantages of a population level approach to healthcare:
- identifying patients at high risk of certain conditions
- supporting people at risk to live healthier lives
- working at scale to provide individual interventions
The speakers, representing primary care and the third sector had a diverse experience of population health. There was a common thread: insight at a population level helps primary care teams provide individual care targeted at specific patients.
Frailty and loneliness
Paramjit Gill is a GP and Professor of General Practice at Warwick Medical School. He describes population healthcare as "looking at health outcomes for a defined population. That defined population could be for a GP practice, cluster, CCG or at a national level."
Professor Gill is investigating variations in care in Coventry. Population health is highlighting the differences and giving insight into the contributing factors. Targeting care at certain frailty patients, such as those who are lonely, is of particular interest.
The stages of this initiative include:
- identifying frailty patients across a cluster of 10 or more GP practices
- combining primary care information for these patients with local authority social care data
- creating heat maps of care package provision for frailty patients
Diabetes information prescriptions
Amy Rylance is Head of Healthcare Engagement and Development at Diabetes UK. In the UK, we spend 10% of the NHS budget on Diabetes, £8 billion goes on complications that are preventable. Diabetes UK is using population-level healthcare to identify:
- ways to improve care
- opportunities for training in primary care
- what we can do for people with diabetes
Amy talks about "working at scale and using big data for individual care". Diabetes UK has created information prescriptions to help patients to take control of their diabetes. These concise, targeted pieces of information contain practical advice for your patients on how to improve their health.
The supplier's view
Dr Jonathan Behr is a GP and Vision's Chief Medical Officer. He describes Vision's responsibility to create solutions that offer evidence for basing interventions.
"We're all at risk of developing something but how do you identify those of us at high risk? Is there a particular intervention that would help a high-risk patient? Population health can identify these people and enable proactive interventions that might stop a disease developing."
Reducing GP workload
Does moving from reactive to proactive care increase GP workload? There is a risk of over alerting GPs and building a tickbox care culture. However, giving GPs a reason to call their patients in can improve engagement and reduce their workload.
Let's look at risk stratification as an example. Population health might show a GP they have ten patients that are at high risk of hospital admission. If we alert the GP and show them what might reduce that risk, they have an opportunity to provide proactive care.
Undiagnosed atrial fibrillation is another example. Case finding across the population can identify at-risk patients. Practice nurses or healthcare assistants can see these patients, and record an ECG at the same time as checking their pulse. Distributing care across the practice team reduces GP workload, and a diagnosis is possible straight away.
A solution for today's healthcare challenges
Uses of population health discussed included:
- Mental health
- NHS Health Checks
- Proactive case finding, such as undiagnosed atrial fibrillation
- Frailty patients who might also suffer from loneliness
- Managing diseases such as acute kidney injury
More than 1,000 people registered to watch the event live. The speakers answered many interesting questions from CCGs and public health teams. It's not too late to watch the event because it's available to view on demand. Register here to catch-up at your convenience.