How the Population Health Management approach helped Jane who spent every day in the front room

One of the key reasons I enjoy my role so much is because I get to help people tackle the problems that matter to them.

Social prescribers like myself keep a very open mind about anyone who comes to see us and make sure to offer a full range of interventions which might help improve their health and well-being.

By spending time with the person we help them to unpick the things that are causing concern and help connect them with organisations and activities in their area.

But despite this already being our mantra, my recent involvement with the national Population Health Management (PHM) Development Programme has been a further eye-opener for me helping me and my team go an extra step further towards supporting people in need.

We often see people who have come to the GP surgery looking for help but what we don’t do regularly is actively go out looking for people who need our service.

The PHM approach by the Bedfordshire, Luton and Milton Keynes (BLMK) Integrated Care System is to actively look for people in vulnerable groups.

We set up the Wellbeing Team in February last year offering social prescribing three GP surgeries in the Titan Primary Care Network (PCN).

In one of our surgeries in Bedfordshire we decided to use a PHM approach to identify those with living with heart failure combined with social vulnerabilities.

We know, for example that 90% of people with social vulnerability live on their own and often contact the out of hours GP services or 999, and sometimes ended up in hospital unnecessarily.

So, we started with linked primary and secondary care data. Of our 32,000 PCN population, we identified 116 patients living with heart failure with high deprivation index scores, and after assessing their care records found 37 people who could benefit from being reviewed by one of our team, either a social prescriber, a care co-ordinator, a GP, pharmacist of heart failure nurse

Jane, was one of those people we identified. As well as heart failure, she had  diabetes, schizophrenia, learning difficulties and a thyroid problem. She frequently called GP out of hours or 999 whenever she needed health advice.

I went to visit her at home. Despite having various long-term conditions, Jane had a very limited understanding of her health. She was overweight, and got breathless after walking a very short distance. Any exertion made her dizzy, so she was falling over quite regularly but she didn’t want any walking aids. She had generally poor eyesight – related to her diabetes – but hadn’t had a recent eye test.

She pretty much spent every day in the front room. She had no bed, so slept on the couch. She had no TV, it was dark and depressing, and the furniture wasn’t in the best condition. Her ceiling was really poorly decorated – chunks were actually falling off, and it looked like the whole thing was about to come down.

Our Wellbeing Team worked closely with the council to prioritise much-needed repairs to her flat, and to review her benefits. They introduced some chair-based exercises and made her personal shopper aware of her diabetes to help improve her diet. The pharmacy team optimised her medication, and she has an appointment with the community heart failure team to review her condition.

By building up her knowledge base of what to do in different situations, she has not called 999 or the GP out of hours since the team made contact. Her self-assessed outcome scores have improved and she says she feels fantastic now her home has been redecorated, she’s eating better, able to get out more and feeling less isolated. Thanks to the PHM project, they were able to get a clearer picture of Jane’s situation and make sure she got the extra support she needed.

Social Prescribing link workers are becoming an integral part of the multi-disciplinary team in primary care, and we’re able to provide specialist support to individuals. It’s not just about medical care but helping people to live healthier, more fulfilling lives.

Some people might think PHM sounds a bit too technical, but I’m on the frontline seeing patients on a day to day basis and can honestly say we’re helping people who need us.

Victoria Harding

Vicky leads the Wellbeing Team for Titan Primary Care Network in the Bedfordshire, Luton and Milton Keynes ICS, creating opportunities for patients to receive the best possible support locally. She identifies gaps in local provisions and works with existing or new community groups to create a service that bridges the gap. She has a wide range of community experience in both a healthcare setting and the charitable sector. She is a trained Social Prescriber and enjoys offering support on a one to one basis supporting patients to achieve their goals. She is also a qualified Health Coach and can offer the tools and mindset to sustain the positive changes made by the Social Prescribing interventions.