Benfleet PCNJ PHM Programme
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In Benfleet we are
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seeing demand for services increase year
after year, with more and more patients
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presenting with complex medical
and emotional challenges.
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We were keen to explore new ways of working, using data
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to help predict future health needs and intervene earlier.
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Gaining a deeper understanding
on the needs of the individual
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rather than a doctor simply prescribing a medical solution.
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Just to give you a background, I’ve been
working in NHS for over 12 years
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now and the biggest difference,
what I feel is we always firefight.
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Imagine you have a road
which is prone for accidents.
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You have two options.
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Either you can build a hospital next to it because you know
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there will be more patients or fix the problem.
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So in NHS, I believe we are trying to build those hospitals,
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creating more jobs and roles, but we are
not thinking about fixing the road.
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Why the accident is taking place? Invest in what measures needs to be put.
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Working in community, I strongly believe
if a patient goes into hospital
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for an unplanned admission, that means
we failed them in the community.
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If we don’t do something today, same thing
will happen in next 5 to 10 years.
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So proactive approaches identify those
patients who is going to benefit.
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We want every service, whether it’s health,
social service, voluntary sector.
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All the other services who provide service to
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our patients are aligned together and work together.
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GP practices in Benfleet have been working with other partners
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to identify and support residents at
greatest risk of poor health outcomes.
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A personalised approach has resulted
in a clearer picture of factors
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that can impact on their health and wellbeing.
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So as a health and wellbeing coach,
I make contact with patients first of all
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and I discuss with them what they
would like to achieve in the future.
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One of the people I have helped, his main goal
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was to be able to exercise more and
to actually leave his family home.
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He was struggling with his health
with lower back pain that no one
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at the present time seems to be able
to get to the bottom with.
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He was feeling really low.
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He was feeling tired.
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He had to give up work in 2020 due to COVID 19,
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and he struggled with that process
of not being able to work anymore.
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After just a short amount of time
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he has lost weight, adjusted his diabetes medication
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and decided that he wants to start
racing pigeons again as a hobby.
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His wife has already ordered his pigeons, and most importantly,
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he’s feeling positive about the future.
Your local GP practices are working together with other health and care professionals to see how they can collectively improve the health of their residents. A primary care network is the name of a structure that brings general practitioners together on an area basis, to improve health and wellbeing outcomes for residents. Through delving into the reason for current health challenges, health and care partners can identify a different approach to supporting local people. This is called Population Health Management (PHM).
Benfleet PCN changing their communities health and care
Benfleet PCN, led by Dr Rizwan Khan, Dr Khan and Partners Practice in Benfleet, undertook a population health management led analysis of 48,000 local residents, to identify people with similar health and wellbeing profiles who would benefit from a new approach to their care.
Initially, a group of 63 residents were identified with, so far, over 25 accepting the support of the team at Benfleet. This group of 60 to 74-year-old residents, have several middle and high complexity long-term health conditions including: obesity, depression, hypertension, history of smoking, diabetes with 56% having arthritis. All of which could be better controlled to help prevent or delay serious illness.
Dr Khan, said: ‘We decided to look at this group for an intervention, as we believed we could make a real impact on their lives, to reduce their chances of developing more serious and debilitating conditions in the future.’
We believed we could make a real impact on their lives, to reduce their chances of developing more serious and debilitating conditions in the future.’Dr Riswan Khan, Benfleet PCN
Holistic health care
Benfleet PCN wanted to try a more holistic approach to caring for their patients by looking, not only at their clinical needs, but other factors that can affect wellbeing and happiness. Through working closely with partners, the Benfleet team worked to provide better wraparound support, ensuring that other things that might impact the patient’s health, such as accessing financial support and housing issues were explored.
In the first instance, the health coach Jo, from Castle Point Association of Voluntary Services, arranged a call or home visit to discuss any current personal challenges.
Personal goals were discussed alongside conversations with the individual’s own home support network such as friends and family. Through having a clear picture of each individuals needs, the health coach was then able to signpost to other organisations and activities to help them, i.e., slimming clubs, looking at the person holistically, rather than a collection of medical conditions.
Following the assessments some patients were referred to the Benfleet PCN Alliance Community Team (PACT), run by matron Lohit Krishnamurthy. Upon reviewing the feedback, the health coach and the matron then undertook a holistic healthcare review looking at current medications, physical and mental health issues.
Case study: Listening and understanding and individual’s needs
One of the individuals, a married retired driver and resident in south-east Essex, was identified.
He met with Jo to discuss his goals, his challenges and what he wanted to achieve. It was identified that he wanted to lose weight and exercise, although he finds it difficult. He also said that he struggled with lower back pain, low mood and felt tired and had issues managing his diabetes.
He also talked about how he felt since retiring in 2020 because of COVID-19. Sadly, he felt like he’d lost his purpose in life, stating, “feeling like he is coming to the end of his life.”
While he was extremely happy in his marriage, he struggled and didn’t like others seeing him struggle. He also had not venture far from his home because of his health. He spoke about his concerns around his finances and being able to afford to take part in activities that he would enjoy.
Implementing a tailored health and care plan
Following a discussion around the type of support he needed, the matron recommended making changes to his diet. His low mood was also discussed, following admissions that he ‘little interest or pleasure in doing things’ had ‘thoughts that you would be better off dead or hurting himself in some way.’
They also talked about his general mood, physical health, lower back pain, giddiness, raised blood pressure and shortness of breath when exerting himself.
A review of his diabetes was undertaken, and he agreed to seek support from Therapy For You and look at attending weight loss classes, plus regularly monitor his blood pressure.
Positive changes were immediate with the individual walking around his garden, and a goal set to walk to the post-box with his wife without stopping’ as he wanted to build his stamina.
He has also been making positive steps to take up his hobby of racing pigeons.
Lohit and the gentleman have continued to speak weekly to review his progress. He is starting to feel positive, as he’s lost some weight and is on a new diabetes regime after speaking to the clinical pharmacist.
He’s also feeling more supported by his wife and has started going out more, including appointments at the surgery, something he’s not done since the pandemic. He now has his pigeons that he can see from his window.
The whole team is totally committed to this holistic model and has given us a new way of approaching the health and wellbeing of our residents.Dr Riswan Khan, Benfleet PCN
By working through a Population Health Management lens, the Benfleet team seized an opportunity to look at their residents in a less clinical way, while centring on the patient and their own goals. This has meant that the patient has felt heard, in control and able to make the changes to their lifestyle themselves that will affect their health and wellbeing now and in the future.
Dr Khan said: ‘This programme has been such a positive experience. The whole team is totally committed to this holistic model and has given us a new way of approaching the health and wellbeing of our residents. Working closer with the local voluntary association (CAVS) and the rest of the team in finding health and care solutions has been a great way to build trust and ultimately deliver better, more effective care to the residents of Benfleet’.