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?

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

FAQs

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

https://en.wikipedia.org/wiki/List_of_cognitive_biases

2. Learn about regression to the mean

https://en.wikipedia.org/wiki/Regression_toward_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.

Primary Care Networks – Holding True to Purpose (whilst the old world bites back).

“If you don’t like the way that people are behaving, they are likely to be organising around a purpose that you don’t support.” Julian Pratt in CIHM Manifesto

In May we conducted a set of interviews with PCN leaders and held an open workshop with Nikki Kanani. This blog focuses on the ‘So What’ of Primary Care Networks – their Purpose. You can also see what Nikki has to say in the next blog to be posted.

Emerging Purpose of PCNs

I’ve been watching a trail of conversations on various Whats App groups as GP leaders try to make sense of the size (and voting rights) payments (for people and hours), governance (read payments and what that means for VAT) and partnerships (and conflicts of interest).

This came after excitement at the additional payments for primary care and the focus on collaboration that seemed to build on the emergent trajectory arising from developments such as Primary Care Homes and other collaborations that meet the needs of people with complex needs and work upstream to secure health and wellness.

The two dialogues are not sitting comfortably together. Whilst the nature of organising is never neat and tidy, there seems to be extraordinary confusion over Working at Scale and Economies of Scale, over partnerships and networks, over self-managed emergent change and top down dictat, over CCG determined or Primary Care determined sizing and memberships.

This confusion is sat alongside the pressing immediate issues – the need for a new workforce that may exceed supply, and a growing mental health crisis with little sight of a plan to invest in services. One GP told me that the wait for CBT for someone that was too seriously ill for online support was 11 months.

The lack of clarity about what PCNs are for – what problem they are there to solve – could generate significant beurocracy and ‘meetings’ as a burden that stifles the very innovation they need, and the ‘top down’ requirements are pulling PCN leaders that way.

It reminds me of this power dynamic (Heimans and Timms).

Dynamic, innovative primary care leaders are trying get PCNs off the ground at incredibly short notice, whilst also trying not to get bogged down in the ‘old world’ to the detriment of the need for relational collaboration. The late night weekend Whats Apps are a testament to their focus on doing the right thing and keeping the end point in mind.

Starting Points Matter

As we know from Complex Systems theory (Malby and Fischer 2006) starting points really matter. If the founding conversations for a network are all about power, that is what will play out in the ensuing development. The scrabble to secure the ‘governance’ frameworks for PCNs and the range of invested interest perspectives on what PCNs are really for could drag PCNs back into the very structures they are there to overcome – the world of transactional contracts. Governance becomes how to handle the money rather than its true meaning which is how to make ethical decisions together to secure public value. Governance needs a conversation about ownership (who to give an account too), as yet an absent concept in many of the PCN development discussions as the immediacy of securing the funding ties PCNS into the transactional old power world. Without a clear purpose PCN leaders will struggle to keep sight on the real opportunities of PCNs, or to dismiss overly beurocratic risk adverse interpretations of guidance by CCGs.

All this points different stakeholders holding different purposes, and using power to secure the one they are invested in.

What are PCNs for?

You may well have had a look at my blog on networks where you will see how important it is in any network to be clear about purpose. Without a clear shared purpose how can you collaborate? How can you review how well you are doing; the difference you are making  (which needs to be in service to the shared purpose)? How can you be accountable for taxpayers money? Without clear shared purpose you can only measure the ‘things’ that you have been told to do and whether you have done them – there is no higher innovation narrative. Shared Purpose will hold PCNs into a collaborative network space where ideas can emerge and creative solutions can be designed.

We interviewed 10 leaders of PCNs. From these interviews we found a wide  range of purposes that PCNs are holding at the moment which seem to fall into 2 camps – Economies of Scale (transactional, which will increase demand) and Working at Scale in Networks (which can meet need and reduce demand).

The Range of Current Purposes Held by PCNs

These purposes were not all held by every PCN, rather a mix is held by each PCN. (See footnote from the list from the Nuffield Trust)

1.Networks Working at Scale

  1. Learning and innovation
  2. Delivering complex care/ integrated care (for some as part of the ICS) together
  3. Support communities to help themselves – increasing community assets 
  4. Get upstream into prevention by collaborating with schools/ nurseries/ families 
  5. Act as an integrator – connecting and enabling partners

2. Transactional Economies of Scale

  1. Alleviate GP pressures (with new staff), improve workload and therefore improve workforce job satisfaction 
  2. To get the income (practices won’t survive without the NCDES) and scalable investment  
  3. Deliver extended hours
  4. Sort out failing / struggling practices

This list of purposes also seems to fit into the Old Power (transactional) / New Power (network) values.

However they do not all sit comfortably together. Extending hours is symptom management and doesn’t get to the root of the issue. Collaborating on upstream issues, working with communities on the social determinants really does reach into those causal issues. Taking a needs based population approach has the hope of enabling primary care to make a difference; taking a deficit demand based approach will sink primary care. These two approaches need two different management and leadership approaches. Economies of scale requires partnerships and MOUs. Working at Scale needs collaborative intent and self-organising networks which may over time develop into a new organizational form but as the old adage goes – form follows function, it will take time for new collaborations working on meeting need to develop the relationships required to secure an organizational form that works for the members and their local population.

Moreover is you see my blog on Working at Scale you will also see that not everything happens at the scale of a PCN.

Exploring the potential purposes of PCNs

1. Learning and Innovation

For instance the best scale for Learning and Innovation is borough / Federation – you need a wide enough diversity of tacit knowledge alongside enough members to secure effective knowledge brokering to bring the very best evidence and experience to bear on local problems.  A PCN whilst is should be a learning system, needs to collaborate at a bigger scale for Learning and Innovation to be its core purpose.

2. Delivering complex care/ integrated care

This does make sense at a PCN scale where the scale incorporates the natural boundaries of collaborating services (community, MH, third sectors, out of hours). Evidence from other countries demonstrates that you can develop algorythms where the PCN is the next step up from General Practice before the need for secondary care admission.

3. Supporting communities to help themselves and Getting Upstream into prevention

This entirely depends on the identity of the population you serve. Communities collaborate to support each other where they recognize each other as from the same community. For some places this will be at General Practice Scale, for some at a small group fo General practices serving one community or a PCN. Its not the General Practices that determine the community- its the community that determines the boundary for doing this collaborative work.

4. Acting as an Integrator

I wasn’t sure why PCNs are best placed for this and how this differs from doing integrated care work.

5. Transactional

All of the transactional purposes are really drivers for MOUs rather than developmental purposes for a collaboration.

Robust General Practice at the Heart

It was heartening to hear Nikki Kanani speaking about the importance of General Practice as the Foundation for PCNs (see video) which concurs with the evidence from High Performing Health Systems. PCNs will fail if General practice is not robust. This means that not only do PCNs need investment so do general practices. Our work in the London Primary Care Quality Academy demonstrates just that – each practice needs to be optimizing its relatonships with the assets in its community, managing failure demand, sorting its back office functions and innovating to meet need (not demand). From this bedrock of great work, the PCN agenda will naturally form – the work that cannot be done in general practice but only at a wider scale.

Footnote: Purpose of PCNS from Nuffield Trust Seminar 4th June 2019

  • Collective provision of Primary Care services especially national service frameworks
  • Fully integrated community based care
  • Building block for wider integrated care system
  • Reduction of avoidable hospital care

References

Malby B and Fischer M (2006) Tools for Change: An Invitation to Dance.

Leading Networks – Top Tips

This blog is to support all new Networks Leaders. For those of you setting up Primary Care Networks please also view this blog on PCNs

Leading Networks – what is different from leading hierarchies?

Engaging Members and Generating Value

What Makes Networks Work

If you want to learn more about networks we have collaborated with NHSI to provide this website – Source4Networks– with all the resources you need.

And of course there is always our book

Are Primary Care Networks solving the right problem? And why they need robust General Practice.

This week my blog is a vlog – setting out the vital need for robust general practice teams within Primary Care Networks, and what work for what scale.

I hope you enjoy this run through of the key issues starting with our assumptions about ‘the problem’ in general practice and the health system that PCNs are going to fix.

Get a cuppa as this one is 35 mins long to do the subject justice.