Moving towards smarter long term condition management

Ever since moving to primary care approx. 9 years ago it has fascinated me that GP practices don't move away from "old-fashioned" long term condition recall. GP software is often clunky and involves hours of manual work, sifting and sorting patients. This was evidenced by one GP proudly showing me their full diabetes register stratification which consisted of 4xA4 pages sellotaped together with hand-drawn tables.

I think most GP practices would struggle to implement a risk stratified approach either due to lack of:

• Technology
• Headspace
• Unclear benefits to attract the change

In this example I take an average asthma register and show the economic and clinical impact of moving towards a risk stratified approach. It could equally be applied across all long term conditions.

Using this model a GP practice could free up 400 nurse appointments, save around ￡3500 per year and increase the quality and quantity of support for those that need it most.

Asthma register - 818 patients

Current model

Team of nurses achieving around 75% annual review (assume 25% have follow up/ad-hoc review) = 766 appointment slots = 192 clinical hours to review these patients indiscriminately by either birth month or surname.

614 unique patients with annual review at end of year = 75% completed reviews

New model

Risk stratification of the asthma register once per year to generate priority review cohorts

Cohort 1 - highest risk asthmatic patients - 287 patients

Separate recall to be reviewed by advanced practitioner(s) only

Assume 85% have annual review and 50% follow up = 366 appointment slots = 92 clinical hours

244 unique patients with annual review

Cohort 2 - medium risk asthmatic patients - 253 patients

Separate recall to be reviewed by ARRS/ allied health professionals

Assume 75% have annual review and 25% follow up = 237 appointment slots = 59 clinical hours

190 unique patients with annual review

Cohort 3 - lower risk asthmatic patients - 278 patients

Separate recall to be reviewed digitally by allied health professionals

Assume 50% have annual review and 25% have single follow up = 174 appointment slots = 43 clinical hours

139 unique patients with annual review

Conclusion

Overall this would lead to an increase of annual reviews from 75% to 84%, free up 400 nurse appointments to support access and proactive care, save money and increase the quality and quantity of asthma reviews for those who are most symptomatic and at most risk of exacerbations.

The new overarching PCN specification will focus on supporting resilience and care delivery, improving health outcomes, reducing health inequalities and targeting resource to deliver proactive care.