Back to Better

Sharing the health and care innovations made possible during the pandemic

Alongside the frustrations, difficulties and challenges of Covid-19, many great things are happening in the healthcare system. We have captured and classify them so that we don’t end up going back too old, less effective habits. We also bear witness to the many testing and difficult experiences.

You can contribute your experience and views by taking part in the survey here

What do you want to keep from this time? Lessons for the NHS – don’t let the ‘old world bite back*’

You can contribute your experience and views by taking part in the survey here

Alongside the frustrations, difficulties and challenges of the pandemic, many great things are happening in the healthcare system. We undertook a survey to help the NHS remember and build on them, so that we don’t end up going back too old, less effective habits. What we heard about what the NHS wants to keep was astounding.

The survey showed that almost overnight, for some people, the NHS turned into a high performing health system. NHS transformation boards have been working for years to lead the NHS into New Models of Care that mimic those that are already bread and butter in high performing health systems around the world – Intermountain, Nuka, Jonkoping, Buurtzorg – places that have been visited by countless NHS staff, and that have mentored, coached and supervised the NHS over many years. Yet within all the things staff wanted to keep, were all the key conditions of these very effective health systems.

Many will describe the digital innovation and yes thats part of it, but in reading the responses to the survey we found so much more:

What has worked has been relational conditions that underpin all high performing health systems, achieved by extraordinary professionals and communities, unleashed from the tyranny of mistrust and dependency creating control.

Whatever happens next NHS Leaders can proactively capture these vital changes and make them permanent. This is what it will take:

Valued Staff: Being valued as staff and having the energy to focus on the job.

It was shocking to hear clinical staff talking about the value of being able to access food and water 24/7; of having somewhere to go to deal with stress and grief; things just not available in the day to day NHS. Proper care for NHS staff doing difficult work has to stay.

21st Century Tools: Engagement with a new set of digital tools and ways of working

Rapid implementation of so many tools that have been on the periphery for a long time waiting for adoption. In Primary Care particularly Telephone Triage has worked well and video consultation is something respondents wished to keep. This has to stay.

Engaged Leaders: A visible and engaged leadership

NHS staff engaged by leaders that listen, who are visible and who collaborate. This has to stay.

Basics and care foundations finally fixed, reorganised. Sorted.

Data Sharing between NHS and LA; Getting software and hardware to enable staff to consult from home “inconceivable a month ago”; Meetings by zoom when they are needed to do relevant rapid problem solving; massive reduction in paperwork for discharge and referrals. All of these show the ‘back office’ systems now orientating to support effective clinical practice. This has to stay.

A joined-up local health system getting things done

Local collaborative problem solving has worked. Professionals working in different organisations or in siloed departments are suddenly able to work together. The discharge to assess debacle has been sorted overnight. Virtual rounds in care homes, collective redesign of pathways agreed, direct communication across boundaries. Local teams, leaders, charities, and businesses are finding a way through problems that cannot be solved nationally (and the centre should not wrestle control back). We are the most hierarchical centralised democracy in the western world and that has to change. Local decision-making to meet local need must stay.

Great Teams: We are working day-to-day as a real team

Overwhelmingly NHS staff talked about the value of time to connect as a team to peer review decisions, to support each other, to learn and to adapt. The value of being part of a team you know, where you can build relationships and work together is critical for good quality care. This must stay. The production line model of working has to stop.

Being Professional: A huge increase in ‘professional’ working behaviour

Professional practice requires peer review, evidence based decision making, learning, scrutiny and collaboration to meet patient need. This has been lost or conceded as risk management and contracting for tasks dominated. Professionals described the joy of learning together, moving out from specialisms to collaborate, taking peer reviewed decisions with confidence. This must stay.

Decisions based on needs and what’s best with proactive planning for the future

Prevention is back on the agenda. Clinicians are moving out of the reactive mode and thinking proactively about their populations needs and how to meet them from anticipatory care plans to chronic disease management. Thinking together across the system about how to intervene earlier. This must stay.

Patients as Partners: Mutual decision-making and partnership with patients

A significant change has been where clinicians have moved into a new relationship with patients and carers – more mutual, more respectful and more understanding (both ways). Informed shared decision-making. This must stay.

Community connections, collaboration and support

As the NHS demonstrated its human vulnerability and reached out for help, communities were there. This rapid transformation of the NHS’s attitude to communities in the deficit model of ‘needy’ to the asset model of communities with resources has to stay.

And so we come to the evidence on high-performing health systems (Baker & Denis 2011). They all have these relational conditions, as well as access to great data to inform their decisions. We have seen that it’s possible for the NHS to do this too.

We also asked what NHS staff thought should never be repeated. This is what they said:

Already the old world is biting back, the culture of the NHS beurocracy, power which resides in the hierarchy, the resistance to local devolution, is already back using transactional contracting methods. The NHS that has experienced first hand the power of being a real quality system can choose that future by paying attention to these relationships and conditions; or it can react like Pavlov’s dog to the bait of contracting. Choose relationships, Choose networks, Choose systems, Choose collaboration, Choose professional responsibility, Choose to be proactive and make the new NHS.

You can contribute your experience and views by taking part in the survey here

FOOTNOTE: These are conditions that I set out in 2016 (The Old World Bites Back) – suggesting that by 2020 health and care would be collaborating to meet population health need with systems leadership that invested in data and people, with a clear purpose in partnership with people and communities. The NHS has not managed to do it (as I predicted) by project management. It would be wrong to re-write the story of Covid and credit the current ‘transformation’ to command and control management for the crisis.

Survey Respondents:


Baker, GR., Denis, JL. (2011) A Comparative Study of Three Transformative Healthcare Systems: Lessons for Canada. Canadian Foundation for Healthcare Improvement.

* With thanks to Myron Rogers for the quote -whose interview on Leading through the Pandemic you can see here

Leading Through the Pandemic: Lessons for the NHS

Prof Becky Malby interviews thought leaders to inform and guide NHS leaders through the current context.

Interview 7: Tania Eber – The Power of Self Managed Teams. Lessons from Buurtzorg

I have been talking to leaders from across the globe about how to take a proactive approach to leading through the pandemic. At the same time, we undertook a survey of what NHS staff wanted to keep and what they never wanted to see again. From this we identifies 10 leaps forward – which, as it happened, mirrored the key cultural conditions evident in high performing health systems. One of these key conditions was being able to work well as a self-managed team. This week I am talking to Tania Eber who has worked with Buurtzorg on their fundamental commitment to self-managed teams and the benefits that has reaped for population health and for the staff what work there. You can find Tania at @TaniaODC

Interview 6: Charlotte Augst – The Answers are in the Community.

This week I have invited Charlotte Augst to talk with me about the Community Response and the new relationship being forged in some places between health services and local people. We cover the results of the survey that shows how much the NHS has appreciated and been surprised by how Communities have gifted their time and support.

Interview 5: Dr Brent James – Lessons from High Performing Health Systems. Building learning into the NHS’s future

This week I have invited Brent James to talk with me about learning systems. Last week I sent out a survey asking people working in the NHS what they want to keep from this time, what they never want to happen again, and the opportunities for the NHS. The results looked very like the culture and operational model of Intermountain Healthcare. I asked Brent how can we make sure the best of the way the NHS has worked well sticks. He said “Dont ask for permission just do it!”

Interview 4: Liz de Wet – The Personal Leadership Challenge

This week we move on from focusing on the systemic challenge of the pandemic to discuss how as leaders we ourselves are the instrument, and how in our practice we shape the future by how we engage with this context. Taking a more personal approach Liz de Wet brings her global experience in leadership practice in a more intimate conversation on how we lead.

Interview 3: Myron Rogers – How to Lead Adaptive Change

Last week I talked to Irwin Turbitt about recognising the adaptive challenge that this pandemic presents for the health system.  This week I am talking with Myron Rogers and we are going to discuss how to lead this emergent adaptive work. What principles and practices will we need to draw on?

In our discussion we touch on this vlog by Dayna Cunningham, Community Involvement Innovators lab at MIT, on her experience of the pandemic

Interview 2: Irwin Turbitt – The Adaptive Challenge

My second interview is with Irwin Turbitt discussing the adaptive challenge of the pandemic and how to harness the relationships generated in the crisis into a new collaborative effort in the future.

Interview 1: Prof Keith Grint From Crisis to Adaptive Leadership

The first interview is with Keith Grint, Emeritus Professor at Warwick University on the lessons from his work on leading Critical, Tame and Wicked Problems. We discuss the interplay between command and control and adaptive leadership, the role of soft power, and how to ensure you are the best decision-maker you can be.

Primary Care – doing the right thing

Three conversations this week showed how easy it is to get seduced into doing the wrong thing. All of these showed that if primary care focuses its change effort on fad or ill informed policy it will just make things worse. We have to take an evidence based view.

These were the conversations:

  • Helen Carr, Local Care Direct West Yorkshire about who is accessing out of hours and its young people
  • Ollie Hart, GP from Sheffield on twitter about Marmot 2
  • The Steering Group of the RSA Future of Health and Care the topic is in the group title!

Primary Care for Young People

You have seen this slide before – where we show that young people aged 7-24 are not accessing GP appointments.

What Helen told me was shocking. She said that across West Yorkshire 30% of the out of hours demand was for young people aged 16 and under.

Earlier in the week I’d been contacted by a network of PCNs who had decided to tackle the issue primary care for young people – which is really great. They were going to go to schools and tell them about social prescribing and the services they were offering. The data above tells us that walking into a GP practice is not what young people want or need. I suggested two things to the PCN Network to think about:

  1. Be clear that you are prepared to spend the allocation per head you receive for these young people on meeting their needs. It may well be that you need to offer something quite different from traditional services.
  2. Yes go out to schools but be prepared to listen first – what does the school know about the health needs of young people in their care (when I was a school governor the pastoral team were overwhelmed with young people with anxiety, self-harming, drugs, poor family life..); and then listen to the young people themselves – what is it that helps them live a good and healthy life? Where do they go for help? What would work for them?

Marmot, Poverty and Primary Care

When you read my blogs on people who attend frequently in Primary Care you will see that there are 3 main issues:

  • People who need continuity of care
  • People who need a multidisciplinary team to meet their complex needs
  • People who are struggling with life – not just loneliness, but poverty.

My vlog (at the bottom of this blog) on working with general practice and their communities, shows that when you ask communities they say that to live a good and healthy life firstly people need shelter, stable finances, family and friends, meaningful lives and work etc. But the Marmot Review 10 years on shows us how these basic needs are not being met and are undermining people’s health:

  • “For part of the decade 2010-2020 life expectancy actually fell in the most deprived communities outside London for women and in some regions for men. For men and women everywhere the time spent in poor health is increasing.
  • Put simply, if health has stopped improving it is a sign that society has stopped improving.
  • The fact that austerity was followed by failure of health to improve and widening health inequalities does not prove that the one caused the other. That said, the link is entirely plausible, given what has happened to the determinants of health.” (p5) And this is the graph that demonstrates this (p10)
“Analysis from the Institute for Fiscal Studies shows how the more deprived areas, with greatest need, had the greatest reductions in per person spending, shown in Figure 1.2. The cuts over the period shown have been regressive and inequitable – they have been greatest in areas where need is highest and conditions are generally worse. It is likely that the cuts have harmed health and contributed to widening health inequalities in the short term and are highly likely to do so over the longer term.” p9

General Practice is experiencing an increase in demand directly related to people’s social conditions. No amount of social prescribing and extended hours will solve this problem – it needs to be solved at source. I don’t know how many appointments are for poverty-created health needs, but we need to find out. As I said at the RCGP conference – primary care has to understand need so it can push back against policies that are sticking plasters not problem solvers. Once we know this we can work with local government, our political representatives and the public to help people. I would argue GPs have a professional duty to do so.

Another key issue here is the disproportionate impact for the minority ethnic population , and that leads me to the last conversation

Modelling the future to reinforce the status quo

I was at a meeting of the Advisory Group for the RSA’s Future of Health and Care work. One area that is generating a lot of attention is genome sequencing and the ability to predict people’s health almost from birth. However a few weeks ago I’d chaired a cancer conference for Inspire2Live (a brilliant organisation that brings the best of science, clinical knowledge and citizen leadership together) rather cleverly called “Evidence, Arrogance, Ignorance, Eminence’ – which rather sums up the NHS dilemma. These presentations got to the heart of the issues:

  • Bob Weinberg (Whitehead Boston Institute) – the more we investigate cancer the more it outsmarts us – the science is telling us (a) we have to stop over treating and be more nuanced in care and (b) prevention is more effective and for lung cancer the only solution is to reduce incidence. Presentation . Have a look at the impact of education level (thank you Bob)
  • Olufunmilayo Olopade (University of Chicago)  – the research on breast cancer is primarily from studies of white western women and it doesn’t translate to ethnic minority groups. Presentation
  • Patrick Connor (pharmaceutical company AstraZeneca) – whist science has almost eliminated some cancers, we need to take a differnt tack with others – improving quality of life, and working on prevention already working on new grants for collaboration. Presentation

No amount of genome sequencing is going to help if (a) our data for determining solutions does note reflect the ethnic mix of our population and (b) we don’t address the critical issues of living healthy lives …. we are back to Marmot. The future of health and care is in living well not treating disease accelerated by poor social norms (poverty, investment in education…).

Marmot, M., Allen, J., Boyce,T., Goldblatt, P., Morrison, J. (2020) Health
equity in England: The Marmot Review 10 years on. London: Institute of Health Equity.

Solving the Problems in Primary Care.

The solutions the DES was looking for….

After the push back on the draft DES what should PCNs be doing themselves to secure better quality primary care, reduce demand and improve population health?

I’ve written plenty of blogs on PC so this one is an update on key issues where you can make a difference without centrally prescribed solutions.


Whilst there are endless contributions about PCNs having to find their own purpose and NHSE not prescribing a sole purpose, the draft DES demonstrated the disconnect between what PCN CDs thought PCNs were for and how to deliver that, and NHSE’s approach.

To find out what PCNs think they are for I set up a survey which you can fill in here sharing your Purpose with colleague PCNs (and where you can see theirs) which will give you access to the emerging picture of how PCNs describe their raison d’etre and what they are focusing on.

The survey shows the following direction in terms of purpose:

“To develop integrated working and sharing across practices to provide resilience and allow for innovation and excellent community based care for patients.”

“Strengthened practices, empowered community, support of the vulnerable”

“Joined up working to address issues one at a time across the PCN to improve care”

The responses so far focus on working collaboratively to:

  • Meet complex needs through integration, and secure access for marginalised people
  • Improve the quality of care for the whole population,
  • Support sustainable general practice and a resilient workforce
  • Empower communities

On the whole these mirror my proposal in terms of domains of work with reference to other health systems internationally:

  • Complex Integrated Care
  • Reducing unwarranted variation
  • Collaborating with Communities

Any purpose must be described in a way that you would know if you’d achieved it – these PCN ones signal direction but they are not quite there yet in terms of specificity along the lines of some famous ones (e.g. RNLI – a charity that saves lives at sea).

Without purpose PCNs will, like the rest of the system, be reactive rather than proactive. And it’s being reactive that has generated the crisis in PC.

So NHSE should be heartened from those that have participated so far, that the direction of travel they describe will secure quality primary care. But the next year is crucial – the same PCNs have been wise in where they are focusing their efforts, getting member practices on board, collaborating on complex needs, securing a workforce to meet needs. Disrupting the formation of these collaborative networks will mean these PCNs will not achieve their purpose (that and unsophisticated metrics for monitoring see below on averages). And this was the push back on the Draft DES – PCNs need space to understand the problems they face and build the relationships to collaborate.

Step one is to get a clear purpose and determine your focus for the coming year. Then direct your development money at achieving that. Assuming yours will be along the lines of those above here are some updates:

Meeting Complex Needs – Acuity

I’ve talked before about ‘know your list’ – if you know the patterns of people using your services (and other services e.g.A&E) you can start to be proactive in meeting needs. This means you have to differentiate your list. In the blogs on Frequent Attenders here and here we identified that people who turn up frequently are not all the same sort of people. We share how you might differentiate the ‘type’ of FA. Our proposition is that in all practices there are varying degrees of ‘acuity’. Here is an example of the range of complexity for the whole system and how to differentiate within a practice

One Surgery devised a project to improve how they triage, care for, and provide continuity to patients who attend their surgery the most (>30 attendances in last year), using an Emis code within our Care Plan template to trigger a “Patient Access Contract”. Over a 12 week period for 25 people with the Access Contract, the data shows a reduction in all appointments of 43% (67 less appointments for 25 patients), a reduction in the number of clinicians involved by 45%, and a reduction in OOH contacts by 56%, suggesting that improved continuity can reduce demand on appointments and improve care. This is the first iteration of their innovation in reducing the number of people who attend frequently. They are going on to explore even better ways of identifying and proactively securing continuity.

The only health warning on this is the regression to the mean –  we know that a % of people who attend frequently do just stop attending frequently in the subsequent year, so this is a great start and its good to look even deeper for the patterns over time.

Care Homes

There was a fair degree of uproar at the care home requirement in the draft spec. However the direction of travel was supported. You can find an overview of ‘what works in care homes’ here and I’ve popped a googledrive with evidence summaries here (if you have more do send and I’ll add). It triggered the sharing of multiple examples of dedicated teams of nurses, ward rounds, paramedic hot lines, GP alignment, and concerns that the DES would disband the best practice that has emerged.

People who live in Care Homes have increasingly complex needs and need continuity. Staff working in Care Homes are in the lowest 10% of the pay scale, are often on zero hours contracts, and there is a high turnover of staff (Roy Lilley, Gimme Strength 15th January 2020). It’s tough working in care homes, and even tougher if you are trying to navigate the different requirements and care plans of practices where the residents are registered. We know aligning care homes to practices improves the quality of care for people who live there – and they spend less time in hospital. As above in the section on acuity – having continuity makes a real difference as does valuing and supporting people who care for these folk. So given this is known, why isn’t primary care doing this everywhere? My experience is that many Practices have found ways of working with their CCG and Local Council to solve the problem. But there are examples where this is not happening – often a mix of a lack of imagination about funding and Practices being intransigent. It doesn’t require a DES, it requires learning from those who have worked it out, and for a collaborative approach to funding. Proactive management improves people’s lives, reduces overall costs and reduces demands on general practice overall, but it does need the CCGs to find ways to fund it. My sense is that PCNs can solve this one without a DES – and should.

Here are a couple of amazing examples:

“For several years we have a LES for GP care home rounds and one care home per Practice. It works, our practice does weekly rounds and we have the lowest rate of unplanned admissions for dementia patients in the county.”

“We have GP weekly ward round. GPs are supported by community nurse practitioners from community services. We were one of the care home vanguards. Secondary care geriatricians support weekly MDT. We have case management and pharmacist support. We have developed fantastic relationships with care home staff we support & help each other. It reduces overall demand for GPs.”

Social Prescribing

To help people struggling with life you need to recognise their assets, and make the most of the assets in your community to generate a network of local people (volunteers) who can help each other, lead by practice/patient/community champions who will nurture and value and grow the volunteers. See this blog.

Social prescribers can help that happen if they have skills in community building, and they should have. Without that SPs will be inundated with the need for appointments with people who need ‘connecting’ – and they will never meet the need. As we are seeing, SPs are finding that their appointments are filled quickly. Sucking up what should be the role of community building into the NHS won’t work. You can see more in my blog on this here.

SP came out of fantastic examples of success. These had at their essence, community building; face to face appointments for people who need help navigating the system; support to be able to make personal choices; help with their coping strategies; and leadership of this combined system. Those transactional models that are emerging will increase demand and will not reduce workload. Just a reminder from my SP blog

Metrics that relate to the transactional model (number of appointments) mirrors the problems in general practice. We provided a set of metrics for SP based on models that have worked and have demonstrable impact in terms of people living well and reducing their demand on the NHS. This is what we found in The Asset Based Health Inquiry. How best to develop social prescribing? (page 17)

“We suggest metrics along these lines that get to the heart of the intent of a primary care model of social prescribing:

  1. Increase in numbers of friends
  2. Proliferation of citizen-led not sector-led lifestyle support.
  3. Primary care ‘coverage’ to touch the whole population in a way that is more fairly and equally distributed.
  4. Reduced demand on general practice, meeting people’s needs and better overall health.”

Reducing Unwarranted Variation – Understanding Primary Care

Underneath all of this is a fundamental difficulty in understanding Primary Care. This blog isn’t long enough to go into the details – I’ll ask Nick Downham to help us out here – but one thing is for sure, getting all practices to the ‘average’ of them all is not securing quality nor will it solve the problems in PC.

I had a rather odd experience recently where a practice was below average on out patient referrals one year and above (a bit) in the next year and the CCG wanted to know what the problem was. The average had gone up because all the PCN practices had improved!!! It wasn’t a problem, the average had changed. Somehow getting to average will solve A&E admits, referrals etc. etc? Of course it doesn’t. There needs to be a fundamental change in understanding at CCG level about what they are commissioning for (it seems to be reduced A&E admits rather than people living healthy lives, and there is a belief that will reduce secondary care costs), how the metrics they use relate to what they are commissioning for (A&E admits are not just about PC nor are all A&E Admits bad, AND you need to understand what sort of A&E admits you need to reduce and by how much – i.e. what’s good practice and what’s possible). Another GP practice challenged this narrative to find that the A&E admits their CCG wanted to reduce wasn’t anything to do with their practice.

So another blog to follow on how you reduce unwarranted variation in primary care but the starting place has to be:

  • What is the need for PC that we are trying to meet?
  • How much of that is best provided by health?
  • What is all the evidence about how best to meet that need?
  • Are we using that evidence to develop our own responses to need?
  • Are we doing all we can to not make our own work?
  • Have we got metrics in place that help us understand what we are doing and whether its’ working?
  • Are we peer reviewing our work and learning together about how best to delivery primary care?

At the heart of all of this is data. PCNs are getting a range of support to meet needs, but they need help understanding population need, understanding variation and acuity, differentiating their list, understanding if what they are doing is making a difference. As yet there is no additional provision for data support to understand all these key factors. If there is one thing that will help PCNs get off the ground its data.

An Asset Based Approach to Health – the 3 things you should know about social prescribing

The Asset-Based Health Inquiry launches this week, investigating how best to develop social prescribing. You may have read previous blogs here on how best to collaborate with communities –  ‘Them and Us” about the power of citizen leadership;  ‘Primary Care and Scale – who should we be collaborating with?’ setting out the need to build out from communities not artificially mandate a scale for working with populations that doesn’t recognise existing community identities.

The report intends to shed light on the amazing work that is already happening. Perhaps the best advice we can give is this:

  1. Don’t add Social Prescribing on as another project. There are real people making real connections in the community, and health teams already partnering with communities – start there. Learn from them, grow and spread their approach. We met example after example of great work happening. It might not be in primary care, so lift your eyes and seek out people taking an asset-based approach in local government, mental health as well.  
  2. Get out of the way. An asset-based approach generates masses of gifted time, energy, care and compassion. It’s not a service. It’s a way of being part of a community and health professionals can take part but they can’t dictate; they can create the opportunities but then as Alison Cameron says – they need to ‘get out of the way’
  3. When it works its not a service add-on; it’s a whole way of relating – redefining roles in the practice and re-shaping the way professional relate too and with people in communities. Where it worked people lived and breathed non-judgmental, purposeful, positive belief in and experience of working with all manner of people trusting their potential. Where it stalled it was a service provided by professionals to local people.
  4. Count friendships. You pay attention to what you count – so what you want more of. We suggest metrics along these lines that get to the heart of the intent of a primary care model of social prescribing:
    • Increase in numbers of friends
    • Proliferation of citizen-led not sector-led lifestyle support.
    • Primary care ‘coverage’ to touch the whole population in a way that is more fairly and equally distributed.
    • Reduced demand on general practice, meeting people’s needs and better overall health
Ali Cameron

You can read the report here. The report has four inspiring case studies – The Alvanley Way (Alvanley Family Practice) The Frome Connections (Frome Medical Centre and Health Connections Mendip) Grenfell: After the Fire (you may have seen the fantastic Fatima Elguenuni at NHS TEDx) Wakefield: Dancing Down the Corridors (Creative Minds, West Yorkshire Partnerships Trust).

We go through a number of dilemmas and myths on purpose, scale, money, metrics, method and language; and the key to developing a sustainable model. For those of you interested in the evidence there is a full literature report too in Section 2.

Here are three things you need to know from the report

1. Start with Need not Demand

You can find more about this here

2. Who Does What – the mix of roles needed

At the heart of supporting people to live good and healthy lives are the need for friends and family, creativity, learning, meaningful activity (hobbies, volunteering), getting out of poverty, navigating the system to get access to services (finances, care, education, health), eating well and being physically and mentally active. No GP appointment can meet this need.

Whilst there is a place for professionals where people need help coping and navigating, the biggest impact comes from people helping each other. The ambition for social prescribing relies on a multitude of volunteers, coordinated by a few volunteer health champions, in turn supported by employed people who nurture, facilitate, develop, ensure probity and governance, and broker funding. Where the ambition of ‘social prescribing’ works well at scale it had this mixture of roles.

3. What is is and What it isn’t

Employing a link worker in itself does not constitute social prescribing.

Where ‘social prescribing’ – taking an asset-based approach works it changes not just the relationship with local people, but how the NHS / Primary Care goes about its work. It catalyses or is part of a new model of care. That means it will evolve, and as it does so no doubt the language will change too.

The energy, exuberance, and happiness we found on our visits was hard to describe but those we met were definitely living a better life.

Here is a Vlog with all that on it!!

Becky Malby

Malby B, Boyle D, Wildman J, Smith S, Ben Omar S (2019). The Asset Based Health Inquiry. How best to develop social prescribing. Health Systems Innovation Lab. London South Bank University

Frequent Attendance – the work of practices and PCNs

Becky Malby and Guest Blogger Tony Hufflett (who wrote most of this!)

Understanding Who Attends Frequently

We know that the people who turn up frequently (frequent attenders) in General Practice are now who we think they are. In my last blog on this topic Frequent Attenders – Breaking the Cycle in Primary Care we shared that about about half of these people are ‘struggling with life’ and not the stereotypical ‘complex chronic co-morbidities’ that typifies the discussion about how to manage them.

Since then we have looked a deeper at the data from across a dozen practices. What surprises us overall is how little is known in any general practice about who these people are and why they attend. What we see is a pattern of generalising the narrative about people who attend frequently from the few who are practically camped out in the practice (the outliers). Tony refers to this as ‘anchoring bias’(1). These 5-10 people are the exception not the rule for frequent attendance.

So who are the majority of people who turn up frequently – the small proportion of people that take up the majority of appointments?

Universally we see that around 5% of a practice’s patients will use around 30-40% or more of GP appointments. These will be a range of weekly to monthly patients –  frequent attenders who come 10-30 times or more a year to see a GP. In my last blog I set out how to understand and meet these people’s needs.

We find it helpful to zoom in on the top 100 patient attenders at a practice, to ask the practice to review and spot patterns. It’s a large enough number to escape from individual extreme cases.

In these top 100 patient attenders we will see huge variation between practices:

  • Mental health conditions: as few as 10 to as many as 50 patients with registered MH conditions
  • Two or more long-term conditions:  from a majority to a minority of the 100
  • No coded long terms condition: from 8 to 40
  • Aged under 60: as few as 20 to as many as 80

This variation plays itself out very similarly in percentage terms among all people who attend frequently not just the top 100. The nature of frequent attenders is very diverse – young vs old, clinical vs social factors, mental health prevalence and so forth is hugely variable.

There are many ways of looking at this – below for example are five broad typologies of frequent attenders and their prevalence in some practices, some of which are only a few hundred yards apart:

Example variation in typology of frequents across 8 London practices:

But here is the key issue that surprised us.

This variation can’t be explained by population type, it’s more associated with practice’s behaviour than the demographics or health profile of the population.

Of course, a practice’s list demographic and environment will influence this, but it is clear that the system of access and practice priorities and systems are even more dominant. This means that the practice is co-creating the attendance pattern of people who attend frequently.

Most of your top attenders this year will not attend so frequently next year.

That doesn’t sound right does it? But it’s a phenomenon called ‘regression to the mean’. Data shows that only about 30-40% of people attending frequently are long-term consistently high attenders. So sadly, “fixing” these individual cases, outside those 30%-40%, doesn’t fix the skew of resources, and in fact doing nothing at all will make most of them attend less in a year’s time. However, their place will be taken by someone else.  Your pattern of top attendance will look the same in a years’ time but with different patients in it

Real improvement is not about fixing individuals, it’s about spotting patterns, understanding cause and making lasting changes and improvements.

Learning: Practices need first to understand who their frequents are; the different sub-groups within them and most importantly how the practice itself is creating these patterns.

What can the Practice Do?

We set out the key starting points in my previous blog:

  1. Determine who they are and finding out what they need.
  2. Collaborating with your community to take an asset-based approach to meeting needs
  3. Providing Continuity for those it will clearly benefit
  4. Being clear about when acuity has tipped into the place where you need an MDT wider than the practice team (social care, mental health)
  5. Look after your infrequent attenders so they don’t become frequent.

Do read the previous blog – but here is an update:

Here are other things that we see directionally and that we believe to be true:

  1. The harder access is, the more that frequents dominate
  2. The larger the practice, the larger the skew tends to be.
  3. A&E Attendance is also high among frequent attenders. Your weekly attenders are likely to have visited A&E multiple times in the last year.
  4. High attendance may be created by poor continuity?


Even in practices where there is a belief in the importance of GP constancy or micro-team work on consistency; or some attempts to create a flagged ‘usual’ doctor, the continuity data is usually still shockingly low for frequent attenders. 

A “typical” person who is attending frequently, based on a median across 12 different practices will:

  • Have had 15-20 GP appointments in the last year (cost to the practice over £1000)
  • And seen 8-10 different GPS, none for more than 1/3rd of those appointments
  • Case notes will often reveal multiple repeated tests and looped diagnoses

The only exception appears to be when there is a practice-wide strong commitment to achieving continuity and very clear system starting at reception to guide patients towards it.

What can PCNs do?

Those people who are in your top 10 are people bouncing around the system, they are turning up in multiple services. For these people whilst continuity might help, if they have an acuity which is outside the capability of a single general practice to solve you need wider support.

In my blog on the Purpose of PCNs one clear purpose was Delivering Complex Integrated Care – i.e. collaborating across practices in a place to deliver solutions together with partners  (other services e.g. social care) to meet complex needs. In high performing health systems this is a core and critical purpose for collaborations in Primary Care.

Working with PCNs I suggest that every practice undertakes a ‘deep dive’ into the notes of a few of their ‘top 5-10’ frequent attenders. Make a note of what services they access when (from community to A&E to MH to the practice). List those attendances and the reasons for them. Bring these notes to the PCN meeting and together see if you can spot any patterns. Are there any issues that are common across them all? Can you see something that would help if you worked together with your partner services? These ‘complex but unstable’ patients are being failed by the current system of organising. What can you do differently that stops them bouncing around the service with terrible consequences for themselves and their families?

Too often we talk to PCNs who are overwhelmed by discussions about contracting, DES, VAT – getting sucked into the ‘old transactional world’ of the NHS. It’s a terrible waste of PCN CD skills. The work of PCNs has to make a real difference to patients who cannot be managed in a single practice.

Proactively managing frequent attenders is a win-win-win situation:

  • WIN: for frequent patients themselves in terms of improved healthcare
  • WIN: for the practice in terms of better use of resources
  • WIN: for the rest of the patient list in sharing resource more fairly and making access easier


What have you based this on?

In collaboration with the LSBU Healthcare Innovation Lab, Primary Care Quality Academy, we have worked in detail with 30-40 practices in London. The lab work is a year-long programme with each practice starting with a “data readiness” stage including a practice diary audit of appointment appropriateness and access turn-away rates. Many of them have also collaborated with us in a deep-dive analysis on frequent attenders where we have extracted and analyses a full dataset of appointments

Can practices do this work themselves?

Yes. There is a rich data mine in each practice’s appointment book. However, practices often don’t have the time or ability to mine it. With commitment we believe that this is self-achievable however.

Does extending hours help?

Just providing “more” doesn’t address any of the fundamental challenges and opportunities we’re looking at here.

We do see a small but significant proportion of practices (10-20%) at critical access levels – where it’s really tough for patients to get in at all. Both staff and patients are seriously stressed and it’s not a place where thoughtful improvement decisions can be made. Here the resource skew is even stronger towards those who know the system. 

Further Reading

  1. Anchoring bias and other classic errors we make

2. Learn about regression to the mean

Where To Start – dilemmas of a PCN CD

I’ve been lurking on Whats App groups and meeting with PCNs during their rushed and short meetings. I can see the intent of PCNs getting lost in the bureaucracy of how to be paid for pharmacists, how to manage VAT….. the idea that PCNs will be real networks of collaboration with the ability to solve problems that need them to work together is getting saturated by ‘stuff’ as the old world bite back. It’s getting to the point where the start up noise is drowning out the real long term point of PCNs. In June after we had interviewed a number of PCN Clinical Directors and leaders I put together a blog on Purpose which set out the challenge of doing the transactional stuff in order to be able to do the real work of PCNs – meeting needs that cant be met by a general practice on its own.

It is now August and time to move onto the real work of PCNs before everyone forgets what that is. If PCNs carry on getting bogged down with the transactional, contractual ‘stuff’ they will have nothing left for the real work, and nobody to do that work with.

There is no doubt that some of the architects of PCNs totally get it – their intent is about changing the model of care – the way we meet needs together. So here are some top tips for CD leaders for the coming months:

  1. Prioritise Purpose. Do the things that really matter to your community, you and your collaborating practices.
  2. That means – Discover Needs. Work with your partner practices to find out whose needs are not being met by the current system of delivery. Your practice nurses, receptionists and GPs will have a good hunch, so follow you noses and see what you can find out.
  3. Meet those Needs – work together to solve these complex people’s problems.
  4. Create a legitimate space. Do enough of the ‘stuff’ to make sure you have the air cover to do the real work, and get help for the ‘stuff’ from those that do it well. There are plenty of people working in local NHS organisations who know how to project manage the life out of the NHS, use them for the transactional work.
  5. Make your own luck – involve anyone in the creation of your network that could help, and who is committed to your purpose. Local councillors, community leaders, other services.
  6. That reminds me – you do need to be clear about your purpose in a way that your community can understand it, and will back it because it’s clearly adding value….
  7. Work out who you are accountable too. You are using and spending public money, who do you think can say yes or no to how you do that? Who do you want to be your ‘owners’. There is real power in making that your community rather than the NHS hierarchy.
  8. Develop a membership model that ensures you can have all the benefits of a network – creative solutions, diverse views, peer based collaboration, real impact; that means equality, and a clear view about what being a member means in terms of obligations (joining in ) and expectations (clarity of purpose ), and how you will handle those that don’t pull their weight and those that are over enthusiasts! Predicating a core group of ‘doers and enthusiasts’ also predicts network failure (Malby and Anderson Wallace 2018) its all together or not at all….

There are two key and neglected purposes of PCNs:

  1. Meeting the needs of people who are too complex for a general practice to handle on its own, but not so complex that they are primarily the business of secondary care
  2. Getting upstream into prevention and supporting people who don’t access health

Focus Your Time on the Main Purpose of PCNS: Meeting Complex Needs

In the meetings I’ve been too there is real energy about understanding their communities needs and finding better ways of meeting these. All PCN meetings should have the majority of their time spent on this work. My suggestion is that participating practices bring a ‘deep dive’ notes review of a few of their complex patients – the ones they know are bouncing round the system – mapping all the dates in a year or two where that patient has ‘touched’ the health system (hospital, outpatients, district nurse, GP etc). Here is one set out as a list and a ppt

Which of the patients notes you have reviewed together do you think you can solve at PCN level? Put a couple of hours aside at a PCN meeting and talk this through. It will really help you both clarify what the PCN is for but also what you think you can do better together. If you don’t think you can – who can? ICS? For the ones who you think you could do better for, with the help of others in the system, work out who else you need and bring them to the table. Start designing solutions together with other partners. Collaboration is at the heart of the PCN.

An example of a solution that lies just within the collaborating practices

One group of practices recognises the skills in helping people with tricky leg ulcers and they have a great nurse in one of the practices – what if she supervised all those patients in the PCN, passing her knowledge onto the practice staff and offering skilled review? Here we are in danger of getting into the transactional stuff – the process for this could be bogged down by payments etc, but what if each practice gifted some expertise into the network for a number of sessions? This is the joy of real networks – then no transactional stuff needs to happen.

This is the real work of PCNs. To do it you need to know who is attending frequently and why. We know that about half of people who attend frequently have really complex needs; and about half their problems dissipate over time and another cohort replaces them. The second group are probably the work of general practice, the first group could provide the patients/ people and families who need a more joined up approach.

This is meaningful work, it will engage your practices and generate energy and resources.

Getting upstream into prevention and supporting people who don’t access health

We have found that a lot of people (particularly young people) don’t access services at all – they are storing up problems for later life that could be nipped in the bud.

The red shows how few people are accessing this practice from ages 7 to 28!

Not only that but general practice is there for the whole population, and some people are just not being served.

What do you know about this across all your participating practices? If you had a look at this data you might want to collaborate to reach the younger people who need, and deserve your services.

The next blog will tackle social prescribing, but for now if you look at the time you spend in meetings and you align it so that the majority of the time is to meet the real purpose of your PCN, you will be stopping the old world biting back and have the chance of making a real difference to and with local people.