How collecting the right data and skills helps your patients

Understanding patient demand

Soon after I became a practice manager, I decided to do a quality improvement development programme. I learnt the importance of collecting the right data to help us make the right decisions.

Then I got people in my practice thinking about measurement for improvement — embedding the discipline of making sure we capture baseline data to understand the problem before we put effort into solving it.

One of the first things we looked at was demand. And we quickly found that we didn’t collect data on demand in the fullest sense of the word. We looked at patient demands, but what we didn't look at is all the other things that take time:

• Personal training
• Management meetings
• Staff appraisals
• Other administrative tasks

We began to build that fuller picture. And what became clear is that demand is entirely predictable. Also, by analysing what demand is made up of, you can redesign your team around your population’s actual health needs. That’s when the real benefits can be seen.

Challenging conventions

We started with our partners and salaried GPs first: leaders must show the right behaviours for change to be sustainable. Then we looked at demand and capacity within our team. Back then, the nurses kept saying, “We don't know what to do. We're really, really busy.”

They were always there until 7 or 8 at night. So, I started looking at what they were doing and found they'd never measured what they did. When we did, we realized that 22% of the appointments were Did Not Attends because patients had to wait so long.

Huge amounts of their time were being wasted in different ways. For example, the nurses would arrive at work early in the morning only to undertake tasks that others on the team could have done better.

So, we began to challenge all these behaviours and assumptions:

• We ring-fenced and protected nurses’ time in a stricter way.
• We started thinking about how to use nurses more effectively to support our patients based on evidence rather than what conventions dictated.
• The ambition was also to ensure that staff felt safe and could adhere to their professional code of conduct and work at the top of their license.

Creating the care navigator role

One of the first things we discovered was that many patients requiring home visits didn't necessarily need a doctor. But they also didn't meet the criteria for community services. That's when we employed a frailty nurse named Karen who came from secondary care.

Within 6 months of Karen doing a comprehensive geriatric assessment, we reduced GP home visits by 81%. We also carefully measured Karen’s workload and found that around half of her patients had complex needs but did not need highly skilled clinical care.

In other words, because social services weren’t available to these people, Karen was carrying a caseload of people requiring social care. So, we developed the care navigator role to help people with wider social needs access the services that could help them. 

We trained 2 of our receptionists to become the first care navigators, partly because they saw and knew so much about our patients. We didn’t really have a clear idea of what the role would entail, so we tested different approaches and measured all the way through. 

Social prescribing link workers

Three months later, when we tracked 86 people sent home from hospital, not one needed to see a doctor or nurse because they were all ‘care navigated’ to social prescribing routes. That's really where the idea of social prescribing came from.

Now it’s everywhere. And it's all because of population data, combined with staff in the practice having the courage to experiment and learn, and being enabled and empowered by leaders who wanted to create new interventions to meet population needs.

Securing an occupational therapist

Next, we got a community-based occupational therapist (OT) working alongside our frailty nurse. 

This came about because I had a bit of money. I said to Karen, “If I could give you a present, what would you want?” She said, “I'd want an occupational therapist." So, I spoke to our local hospital’s OT department, and we pulled together a proposal and secured an OT. 

The NHS Confederation and The King’s Fund identified this as a groundbreaking intervention to manage urgent care for older people in primary care. These interventions were featured on national BBC, won several awards and were to later feature in the PCN contract.  

And, oh, the things our OT is doing in general practice now! Helping people with frailty and long-term conditions. Supporting patients while they are in hospital. Pulling them through and helping them back on their feet at the other end. It’s simply amazing.

Why data has been instrumental in caring for patients

In 2023, after 43.5 years of working in the NHS, I finally retired. I’ve had the most amazing career in general practice. I came into my practice to do 3 things:

• Sort out our premises
• Sort out our workforce
• Sort out access
  
  

It's taken me 15 years, but I feel like I've done what I set out to do. That said, there will always be new challenges as both population needs and the model of general practice change. 

I’m immensely proud and privileged to have had this opportunity to work as part of such a dynamic, innovative team. They were brave enough to test new things, some of which — like social prescribing link workers — are now established elements of the primary care workforce.

For me, this is a marker of how powerful population health management can be. 

One of my favourite expressions is 'In God we trust. Everyone else must bring data.' It sums up how instrumental data has been in my career. It's helped me do what I’m truly passionate about, which is caring for people. And for that I’m incredibly grateful.

Even as I end my career, what’s exciting for me is that this is just the beginning for PHM. With the right data, skills, leadership and partnerships, there’s so much more we can and must do to support our patients and staff. I look forward to watching it happen.