Pennine GP Alliance (PGPA) is working with General Practices, National Association of Primary Care and voluntary sector partners to support individual patients in Calderdale who require a high number of GP appointments, indicating that something about their care is not working.
Navigating the healthcare system can be complex for some patients, especially those with multiple/complex conditions or health inequalities, hence making an appointment in general practice may be the only way some patients feel they can have their needs met. This new initiative from Pennine GP Alliance focuses on supporting the patients who present frequently to understand more about their health concerns and how to meet their needs.
A cohort of patients who frequently attend general practice services have been identified to benefit from some extra personalised input to navigate, streamline care, and build their knowledge, skills and confidence in managing their own health and care.
PGPA will also be looking at whether the intervention reduces the demand on general practice and frequency of appointments. By providing the right support at the right time, the initiative seeks to alleviate the pressures on urgent and emergency care services, thus benefiting both patients and the healthcare system at large.
Key to this transformative process is the anticipation of learning how to identify patients at rising risk and enable proactive prevention measures, which will initially be led by PGPAs Digital Transformation Team.
As the initiative progresses, it is set to unlock valuable insights into the root causes of frequent healthcare attendance, ultimately paving the way for proactive strategies to help people navigate the options available and support them in their heath needs.
By tackling the challenges of frequent presentation head-on, this initiative hopes to change the way health care is delivered by general practice in Calderdale, fostering healthier communities and empowering individuals to take charge of their well-being.
Jon Malone, Clinical Director for Lower Valley Primary Care Network and local GP said:
“General practices in Calderdale are using appointment data, population health information and reviewing reasons for attendance for appointments to try and improve the way patients interact with their GP surgery.
We hope this proactive digital transformation project will identify any medical (or non-medical) unmet need for regular appointments, thereby improving the way patients access the local health care system. We also hope that it will help GP surgeries take a more proactive approach to patients’ health and improve patients’ quality of life longer term.
Will Menzies, Chief Executive at Pennine GP Alliance said:
“In Partnership with Calderdale Primary Care Networks, we’re proud to be able to deliver this great initiative which will support GP practices to understand why they may have patients presenting for multiple appointments, and how to better support and empower those individuals.
“We couldn’t do this without funding from the West Yorkshire Integrated Care Board and our Digital Transformation Team, who continue to lead on and support initiatives which focus on the improvement and innovation in the use of digital technology across general practice in Calderdale”
Learn more about the PGPA Digital Transformation Team
Digital and transformation leads support increased access to care for patients, through the adoption of new technology and other initiatives to improve the care offer. This enables PCN staff to work more effectively and improves the sustainability of general practice services. Digital and transformation leads can:
- Develop strategic plans to optimise the use of clinical systems and build a robust digital infrastructure for PCNs working on a range of digital transformation projects such as the use of cloud telephony, digital triage, online signposting, social media, digital wayfinding, promotion of the NHS App.
- Deliver broader transformation projects to:
- improve access to care and support the adoption of population health management
- drive operational efficiency
- enhance staff experience
They support the adoption of national and local initiatives, including integrated working at neighbourhood and place level to improve access to services for patients.
Digital Transformation Officers are what’s called an ‘ARRS’ role. This stands for Additional Roles Reimbursement Scheme which is a programme in the UK designed to expand the primary care workforce by introducing additional roles in general practice, therefore enhancing the quality-of-service patients receive and supporting GPs in managing demanding caseloads.
You can find out more about the work led by the Digital Transformation Team here.