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The Population Health Iceberg and the Role for PCNs

Thursday 20th August 2020

The Population Health Iceberg and the Role for PCNs

In our latest blog, Neil Stevenson, NECS Project Manager talks about Primary Care Networks and how they are responding to COVID-19.

A key element for PCNs is a focus on population health management. But with COVID-19 transforming the landscape, does this focus have to change or should population health and anticipatory care continue to be a core response for PCNs?

As perhaps the Captain of the Titanic might have observed, ‘It’s not the part of the iceberg that you can see that should worry you, it’s the bits you can’t that are the real danger.’

As we continue to cautiously emerge from lockdown we’re on a balance. The letter of the 31st July from Simon Stevenson and Amanda Pritchard (1) makes it clear that we are expecting steady progress in switching services back on to ‘normal’, whilst still being sensitive to local and national fluctuations in COVID-19 (C19). It’s quite clear that dealing with C19 has changed the world and in that sense it’s important to test and understand whether the direction we were heading in still stands.

Life and expectations in primary and community care has changed. Pulse has surveyed GPs, finding that there is a ’tsunami’ of work, particularly coming from secondary care (2). Unsurprisingly, to help hospitals manage and prioritise work, they are asking colleagues in primary care to check and confirm patient requirements and maybe manage patients that have traditionally not fallen within a GP’s care. The BMA have also found that the volume and type of work in primary care is increasing and changing. It’s not against this, but argues that if primary care is to do this it needs to be unfettered – making a renewed case for reductions in duplication, bureaucracy and a simplified system (3,4).

But of course the impact of C19 goes beyond process and systems to individual patients. We are only at the tip of understanding the wider health impact. June’s ‘Aftercare Needs of Patients with Coronavirus’ (5) highlighted the significant need for patient support for those who have been discharged having been admitted to hospital (some 113,000 in England at the 12 August (6)), including:

  • Physical support for patients including specialist respiratory support (particularly when a person has or as at risk of other respiratory disorders), as well as impact on patients with diabetes or existing cardiac conditions. Pre C19 we were only beginning to provide post discharge support for patients who had spent long periods in ICU, this will need to increase. And there’s the need to deal with associated symptoms from fatigue to chronic coughs
  • Psychological issues around cognitive and communication
  • Social support for people particularly in the light of further waves

If that’s the part of the iceberg we can see, it’s got to be noted that it’s an early assessment on people discharged from hospital – what are the implications for those who were managed in the community or care homes who have dealt with ‘the bug’?

And then there’s the rest of us, what did three months of lockdown do for us? PHE’s ‘Wider Impacts of COVID-19’ (7) highlights lots of good intentions that maybe melted over time:

  • Physical activity – numbers reporting meeting the ’30 minute’ daily target deteriorated over time and that eating habits did change over time, with the longer in lockdown the poorer the diet (hence TV programme’s such as Channel 4’s ‘Lose a stone in 21 days’
  • Alcohol – suggestion that consumption stayed stable but underneath that is the potential increase in higher risk groups (plus reported increase in sales in alcohol, particularly beer and cider)
  • Wider well-being – increases in anxiety, plus wider media reports on changes in sleeping patterns, increase in mental health problems with the BBC flagging particular issues for serious mental health

Wider media reporting has quite rightly reflected issues in specific communities and the impact and people with co-morbidities and the socially challenged. Implications are being mapped, and through the fog maybe that’s the visible bit but the wider impact on the health of the population; that’s the bit under the waterline.

One internet definition of an iceberg is that it is ‘small indication of a bigger problem’. The LTP declared a need to focus on the wider population health with the expectation that primary and community would be proactive in dealing with these issues. Key to this was anticipatory care (with it being one of the four strategic priorities for community and primary care set out in the LTP Implementation Framework). The Kings Fund has highlighted the differences that have been made in a range of communities that have come through a targeted approach to population care and specific interventions (ref). These range from the work with the Nuka people in Alaska to town/city action in Kinzital and Jonkoping in Germany and Sweden. Experiences here and the wider accountable care movement in the USA indicate the benefit of an approach that segments and targets action to specific population groups.

Work had begun with PCNs around this in 2019. The PCN Maturity Matrix set out the requirements, from an expectation that they should understand basic population needs, with this developed to fully fledged, targeted intervention guided by a detailed understanding of their population. Within the North East, the 70 PCNs recognised this as a key requirement and pooled resourcing to support a programme of training and development. There’s been recognition that to effectively deploy the additional roles that have been made available, there needs to be an underpinning understanding of population and workforce needs.

And here’s the nub, though we are quite comfortable with the rhetoric that sits round this approach, it’s uncharted waters for PCNs and it will take time to roll out and be effective. There’s a danger that the pressure to respond to COVID019 and getting back to ‘normal’ will push this requirement further away. But that would be a mistake – perhaps now than ever before, we need to understand the population each PCN services. One of the legacies of lockdown could be a deteriorating population – the people who weren’t on risk registers etc. but three months plus of limited activity may have shifted them into (higher) risk categories. Action now with these groups could prevent longer term costs and associated issues. We can’t assume that the information and data we were using from last year is an accurate view of where we are now, so dramatic has been the lockdown break.  PCNs need to be building new knowledge bases to ensure their actions are appropriately targeted.

As American screenwriter Dean Devlin observed ‘the Titanic hit the iceberg not because they could not see it coming but because they could not change direction”

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Third Phase Response to Covid 19 https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/07/Phase-3-letter-July-31-2020.pdf

Hospital tasks dumped on over half of GPs as COVID-19 creates ‘tsunami of extra work’ Pulse https://www.gponline.com/hospital-tasks-dumped-half-gps-covid-19-creates-tsunami-extra-work/article/1687310?bulletin=bulletins/dailynews&utm_medium=EMAIL&utm_campaign=eNews%20Bulletin&utm_source=20200623&utm_content=GP%20Daily%20(309)::www_gponline_com_article__1&email_hash=

In the Balance: 10 Principles BMA https://www.bma.org.uk/media/2487/ten-principles.pdf

Trust GPs to Lead BMA https://cached.offlinehbpl.hbpl.co.uk/NewsAttachments/PGH/Trust-GPs-to-lead.pdf

Gov.UK Covid 19 in the UK Data https://coronavirus.data.gov.uk/healthcare

Wider Impacts of Covid 19 DH https://www.gov.uk/government/publications/wider-impacts-of-covid-19-on-health-monitoring-tool/wider-impacts-of-covid-19-on-health-summary

Population health systems: going beyond integrated care https://www.kingsfund.org.uk/publications/population-health-systems