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"One in ten"
Patients presenting in General Practice with non-medical problems – difficulty accessing housing and benefits, for example – can exacerbate GP workload challenges.
Basingstoke-based Mosaic Healthcare Primary Care Network (Mosaic) was facing this issue – an issue amplified by COVID-19 and the disruption it brought.
They had run a quick audit which revealed around 10% of appointments were taken up by problems for which the underlying cause was non-medical. In the context of increasing and, sometimes, unmanageable GP workloads this was time which could have been used managing more complex health needs.
The practices recognised the benefits of connecting patients to community and voluntary support services – drawing on their skills to meet patient needs in the areas where the clinicians were not the experts.
But for that to work it was fundamental to understand the care needs of the population Mosaic covered, the geographies where need was greatest and what support was available.
So practice manager Paul Butterworth contacted Alison Westmacott, SCW director of Primary Care, looking for the detailed insight he needed.
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The SCW team realised Population Analytics would unlock the insight Paul was looking for.
Mosaic represented three different practices, all with very different patient profiles across urban and rural geographies. A combination of desktop research and old-fashioned walking the streets identified 461 groups and community assets for Mosaic to draw on.
To bring the data to life, SCW created a Population Care Segmentation tool to visualise health needs in the patch.
Using integrated primary and secondary care data previously unavailable to Mosaic, the tool segmented its population by age group and level of healthcare need. It also revealed average spend per head by condition and age band.
Mapping tools allowed Mosaic to see where their patients were concentrated – again broken down by profile – plus where support was and where gaps existed.
The new information freed-up clinicians, patients and staff to engage in different conversations around patient pathways.
And SCW arranged for stakeholder workshops with patient representatives and community groups – national organisations through to local art and drama clubs. Many had not engaged before but were enthusiastic in their support for people who felt isolated within their community.
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Social prescribing
With the population health data now at their fingertips and a much clearer idea of community and support assets, the Mosaic team felt able to bring in a full-time Social Prescribing Link Worker (SPLW).
The SPLW, supported by an administrator, is now connecting patients with non-medical problems to sources of support within the community.
This approach has provided GPs with a non-medical referral option which can operate alongside Mosaic’s medical pathways.
Mosaic clinical director Dr Sam Hullah told us surgeries noticed the positive impact of social prescribing in just a matter of weeks.
Many of the c.700 patients who saw the SPLW during that time have had two or three appointments – appointments which have not taken up GP time.
New, value-add services
- A weekly, on-site multidisciplinary patient review with social services attended by the practice community matron, paramedic and social prescriber
- Citizens Advice delivering daily clinics for patients with housing and benefits concerns
- Musculoskeletal, counselling, podiatry and diet clinics. All fully booked and giving patients access to services up to 10 weeks sooner than might have been the case.
We have received some wonderful feedback. Two ladies discharged yesterday who feel their lives are back on track and are both getting out socialising again and making friends. A blind lady who is so much happier and says I've transformed her life. A gentleman who cares for his wife with dementia who can see a way forward." Mosaic’s first SPLW, Sarah Smith
