We're heading towards a perfect storm. We're living longer, which means more of us live with at least one long-term condition. We're putting more demand on NHS services, but the NHS is under increasing pressure, and there is a shortage of GPs. The situation is not sustainable. Something has to change, and we must reimagine general practice.
Throughout the UK, there are initiatives underway to change primary care service provision:
- GPs are working together. Collaboration is improving the patient experience and making better use of clinical resources.
- GP practices are merging into super-partnerships. A super-partnership can bid for and deliver extended services that fit local needs. These services would be beyond the reach of individual surgeries.
- Multidisciplinary teams are treating and caring for patients. Often, this involves seeing patients in the community, either at home or in home-like settings.
There is a common theme here. You are working with a broader range of clinicians and carers. You're also caring for your patients in a more diverse variety of settings. For this care to be safe, the whole healthcare team needs access to electronic patient records.
Sharing patient records
The technology to share patient records is readily available. You can share medical histories with other local GPs and multidisciplinary teams to:
- Give clinicians sight of medical histories. Critical for appropriate diagnosis and care decisions during patient encounters.
- Add information during federated encounters and feed this back to the patient's GP.
Each healthcare service is different. A community nurse providing short-term care after a hospital discharge needs recent information. However, a GP at an extended hours appointment service needs a full picture of the patient's health.
Vision uses sharing agreements, and it's easy to set up sophisticated sharing on a local level. GPs decide what their sharing policies are for each service:
- What data do you need to share?
- Who needs access?
- Will people need to view records or add information as well?
- Do sharing policies differ depending on job role?
- Are there any sensitive exclusions, that you must not share?
Turning these policies into sharing agreements allows Vision to control local sharing. It's simple but enables sophisticated sharing models at a local level. It's a perfect balance between governance and making information available to improve care.
When you see patients in their homes, you need mobile access to their medical records. Modern apps for phones and tablets let you work with patient records at any time, wherever you are. Vision Anywhere provides 24/7 access to patient records on the device of your choice. There are apps for iPhone, iPad, and Android devices. It's perfect for shared care, home visits, nursing homes and mobile working.
A WHO report on preventing avoidable diseases said:
"The lives of far too many people in the world are blighted by chronic diseases such as heart disease, stroke, cancer, chronic respiratory diseases and diabetes."
Lifestyle advice is commonplace. Public health campaigns improve awareness of the dangers of smoking, alcohol and obesity. What about clinical interventions?
Population health is the science of improving healthcare at scale. It's how towns, cities, and CCGs or health boards manage their patients' health at a macro level. As well as improving outcomes, it can help service providers to make better use of resources.
One use is case finding. Collecting and collating health information about each patient enables centralised healthcare analysis. As well as identifying patients with particular conditions, you can find those at risk of developing them too.
There are three stages of population health:
- Find a cohort of patients who may be at risk of a particular disease burden.
- Apply an intervention to these patients.
- Analyse the outcomes to see if there has been any impact, positive or negative.
Outcomes Manager is Vision’s population health solution. NHS Greenwich CCG uses it to identify patients with long-term conditions.
In a cost-pressured NHS, it was vital that the CCG identified these patients to:
- ensure these patients receive the most appropriate care as early as possible.
- reduce hospital admissions.
- avoid any further complications resulting from their condition.
In its first year of use, it allowed the CCG to identify 4,000 more patients with chronic diseases. Population health is helping to increase life expectancy in the borough. You can download a detailed case study for more information.
The importance of technology
There's no doubt that together, we have to reduce pressure on the NHS. It's easy to overlook technology, but it can make a significant contribution. If you're reimagining general practice, look upon technology as your best friend. Use it to catalyse your success.
Come and talk to us about your biggest healthcare challenge at an event The Kings Fund is organising: Reimagining general practice: innovative ways of delivering care.