Regis Primary Care Network

Providing a proactive, personalised and holistic service for high intensity users of primary care.

AT A GLANCE

CLEAR CHALLENGE

High intensity users were taking up a disproportionate amount of GP and hospital time – accounting for more than 16% of unplanned hospital admissions

KEY CHANGES

A new dedicated HIU service to provide proactive multidisciplinary care providing 20,000 hours of support a year for patients

FORECAST BENEFITS

Enhanced wellbeing for HIUs with improved access to community-based support and potential annual productivity savings of £89,579

THE CHALLENGE

Regis Primary Care Network (PCN) in West Sussex consists of five practices.

High intensity users (HIUs) – patients attending the ED five or more times in 12 months – represented 0.3% of their 103,448 registered patients but accounted for four times the activity for their local health services than the general patient population

Between August 2018 and August 2021, they had more than 17 times the median number of GP appointments and almost 28 times more distinct medications. They accounted for 12.6% ED attendances and 16.3% emergency hospital admissions. A higher percentage of HIUs lived in the most deprived area of Regis.

WHAT WE DID

Frontline staff working in a broad range of roles across the PCN were interviewed to gather information about their experience of managing HIUs. Their feedback was analysed alongside data relating to more than one million appointments, including 13,127 HIU appointments (1.2% of the total) to identify the key challenges relating to the care of this patient group.

CLEAR RECOMMENDATIONS

A new “model” HIU service to be introduced to provide proactive, coordinated and multi-disciplinary care, incorporating many of the wider determinants of health. With 10 roles and 11.78 staff, the service would provide more than 20,000 hours of care a year for patients.

Included in the service would be dedicated care coordinators providing case management and continuity with proactive clinical management of patients with long-term health conditions and structured medication reviews.

Health, wellbeing and psychological support would be offered to patients to help them stay as independent and healthy as possible, both physically and mentally. They would also be able to receive assistance on other matters including benefits, budgeting and housing.

Data and administrative support to be put in place to ensure the right people benefit from the service and to monitor outcomes.

FORECAST IMPACT

Holistic, proactive and coordinated care for HIUs would help address health inequalities, improve access to community-based support and enhance the overall wellbeing of this group of patients.

Potential savings of £303,188 could be generated by a 25% reduction in GP appointments, ED attendances and emergency hospital admissions. The new model of care, including 7,514 hours provided annually by 4.36 WTE data clinicians, would cost the PCN £392,758 resulting in net productivity savings of £89,579.