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Personalised care in PCNs

Personalised care in PCNs
By Emma Wilkinson
6 February 2023

Every clinician who is passionate about personalised care has a ready example at their fingertips. The patient with anxiety and antidepression prescribed medicines until an appointment with a social prescriber leads to them joining a local singing group. Now they no longer take the medicine. Or the elderly gentleman discharged from hospital after a minor heart attack whose only goal is to walk his dog every day – something the blood pressure tablets he is taking are putting are putting a stop to.

Dr Saul Kaufman, St Johns Wood & Maida Vale PCN Clinical Director, says these case studies are vital to explain to clinical staff what is meant by personalised care. It’s changing the question from ‘What’s the matter with you?’ to ‘What matters to you?’, he explains. Getting to grasp with the real meaning of personalised care the first step for PCNs if they wish to make any progress.

The goal in the NHS Long Term Plan is to make personalised care a routine part of the health service. PCNs have been tasked with taking a targeted approach – identifying a local group of patients with an unmet need where proactive social prescribing could improve those health inequalities. Frailty seems to be a sensible (and common), place to start but it could also be dementia, diabetes, chronic pain and so on.

Dr Kaufman explains the four PCNs across Westminster have joined forces. Their focus is on frail patients, socioeconomically deprived groups and those who have high intensity usage of various bits of the health service. They have a team of ‘care connector roles’ which are the social prescribers, care coordinators, care navigators and health and wellbeing coaches.

‘We’re sitting them at the place level, which includes the local authority and voluntary sector, to say this is what is most important to patients, whether that’s a gardening group or yoga group or mosque or whatever. That has to be the starting point, a top-down approach doesn’t really work.’

Dr Nigel Taylor, clinical director of Upper Calder Valley PCN in Hebden Bridge said their key population need was the frail elderly population who were living at home. Their ageing well service is made up of four social prescribing link workers, two care coordinators and an occupational therapist. Through a clinical commissioning group (CCG) bid they have also been able to fund an ageing well nurse, which he says has been the key to the project’s success.

Those over 65 showing up on the frailty index are offered a review. Who that review is with depends on the level of their risk. With the help of the National Association of Primary Care, they have done some work with patient activation measures which correlates with a reduction in primary care contacts for that population he says.

‘They talk about what the patient’s needs might be and they try and encourage them or find them interventions that might be helpful and we’ve got a very active voluntary sector in our patch to signpost people to.’

They’ve also linked up the scheme with their practice pharmacist, Dr Taylor explains, so if appropriate they can be offered a medication review as well. In all 25% of the ARRS work has been dedicated to this proactive work.

He adds: ‘You do have to make sure you protect it as there’s always a drag to pull people into more reactive work.’ The ICB has been very supportive and there are now work going on to replicate this approach across four other PCNs in Calderdale, although the staff involved may differ, he explains.

At Selby Town PCN, clinical director Dr Nicholas Jackson, says it has not been about following the DES but just trying to do the right thing for their population.

‘We’ve got six care coordinators now and they’re looking after dementia, learning disability, frailty, and a small amount of brain cancer social care coordinators and homelessness. They’re developing personal support relationships and personal support plans for people on their caseload.’

Some might be having very intensive input from the team, others it might be one contact and some signposting, the goal is to be flexible, he says. ‘It’s taking work out of general practice which we have the capacity to do or respond to very quickly.’

The care coordination team has an average of 427 contacts a month, about half being new patients. From next month, the team will expand to seven care co-ordinators and will also include safeguarding. They also want to do more work on children and young people in the two most deprived wards.

What is tricky is how to prove the value of what they are doing, he says. They are building qualitative feedback through patient stories, which is working well. ‘I think most of my colleagues would like to understand the impact it has on them that’s really hard to demonstrate something that hasn’t happened. You need metrics that are meaningful.’

The PCN has developed the training package for care coordinators as the team has grown and mentorship and leadership has been keen to the teams’ success, he explains. ‘They’re working with quite a challenging group of people and because they’re not clinical they don’t necessarily have the same support mechanisms.’

One concern that Dr Kaufman has is the potential for PCNs, keen to meet targets on referring patients for social prescribing end up overwhelming the cash-strapped local voluntary sector.

‘The voluntary sector is massively underfunded and that’s a problem we need to acknowledge and work at the system level to address. ‘It takes time and the right approach to see other people’s perspectives,’ he says. It’s best to start small and get it right rather than flooding the system just to tick a box on the IIF, he adds.

In Selby they found there wasn’t a group that existed for people with dementia so the care coodinators set up their own dementia café group. ‘The solution was actually quite simple and really cheap,’ says Dr Jackson. ‘We know there’s lots of evidence for the benefits of reducing social isolation.’

Mohan Sekerem, a GP in Merton and South West London lead for personalised care says a lot of PCNs know what their issues are but getting in place the long-term proactive support is more difficult. They have proven the impact locally in terms of a 30% reduction in GP appointments related to social prescribing but of course that is only one small way of measuring the impact.

‘We looked six months before and six months after but after 12 months it started to regress back to the mean. It may be you deal with the instant problem but for some of these patients it might be better if they have a follow up.’

What is needed, he says, is an open mind and careful consideration of the whole pathway from primary care to voluntary organisations. It might make for a slower start getting personalised care off the ground but it will be more sustainable in the long run.

‘Networks also need to have the confidence to let go, they will want to medicalise things but often this makes it more complicated. There isn’t a magic formula – just work out what the problem is and go see what your community assets are. We should all be doing this.’

Dr Riaz Jetha, director at Health Integration Partners has been working with PCNs to help them develop clinical strategies. He is yet to be convinced that many PCNs fully understand what personalised care is.

There is a list of enablers that are missing, he says, including training, meaningful recording of personalised care plans, ICB support and use of routine use of health data to stratify patients because ‘there’s no point having a scattergun approach’, he says.

He points to previous incentives to create personalised plans for people in care homes that then no one used and just sat on a computer system somewhere.

‘There is no point in these short-term approaches. You can have a DES to work out where your most severely frail people are but there’s no point if there’s no meaning in it, it needs transformational change, he says.

The article first appeared on sister title Pulse PCN

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