Dr Shashidhar Khandavalli has been a GP partner at The Chorley Surgery, Chorley, since 2008 and is now also Clinical Director for Chorley Central Primary Care Network. He tells us how he and colleagues – from across the Lancashire and South Cumbria Integrated Care System – linked people with frailty to data on people needing assisted bin collections.
When we think about our health the last thing that springs to mind are the black, blue and brown bins we put out each week.
But in Chorley, thinking about frailty and bin collections was key to us working with the council and our wider partners to uncover a shared community of people who needed more help.
In Lancashire and South Cumbria (LSC), we’ve recently been on the NHS England Population Health Management programme which helped us think about how we can improve local people’s health in new ways.
As a GP in Chorley and clinical director for the Chorley Central Primary Care Network – the programme gave us the time-out to sit down with colleagues in other teams we wouldn’t usually meet with and deep-dive our data in new proactive ways.
This included specialist data analysts, council colleagues, public health, finance teams and social prescribers to name but a few. Through workshops we got to know each other and get to the nub of the problems we needed to solve in our area.
Our focus were high intensity users of Primary care (greater than 10 visits to the GP practice in a year), were moderately frail and aged 45-60.
In our Thursday workshops, we worked closely with our partners to collate and link datasets to bring a deeper insight to the needs of our identified cohort. We wouldn’t ordinarily have that linked information but by working closely we were able to pinpoint a number of residents we were unaware of in primary care who clearly need more help.
It was through this process that we found that these residents also needed help to have their bins collected. A frail patient to a GP practice was in fact a resident who needed an assisted bin collection to the council – the difference was the language used to describe the individual. Bringing data together we developed a richer contextual picture of the resident and developed a new common ‘language’.
We linked this data across the patch and found people who had limited mobility, some with fewer social links and some who were isolated – all who needed more support. Once we had a list of these people we were able to work with our collective practice teams including a social prescriber (link worker) to write to the residents and ask them if they wanted to be involved in a project.
Our link workers visited and interviewed the residents in their home to uncover their unmet needs in a holistic manner. We were able to think about their mental health, physical and social needs all in one assessment and then make personalised recommendations for that person.
It could have meant putting them in touch with local groups to help with loneliness, a visit to the GP if medical needs were apparent, help with healthy eating or contacting the council team about an issue with their environment.
One aspect we weren’t expecting was that 90 per cent of the people we discovered were obese and this created new challenges – but crucially, more opportunities. What often becomes clear from drilling into data and really understanding our communities and individuals, is that people’s needs are generally related to wider structural social issues.
Is their housing acceptable, do they live with noisy neighbours, extreme pollution, a lack of green spaces, no parks to visit, only fast food shops nearby?
If so, it becomes much more difficult to lead a healthy life – taking regular exercise, eating healthily, existing happily in a nice environment at home. If these areas of people’s lives are compromised they can result in mental health problems, obesity, unhappiness and loneliness, much of which falls to rising numbers in the doctor’s chair.
We cannot fix these problems on our own. However, by helping our communities on a local and individual basis alongside our fantastic council and third sector colleagues, who hold the key to so much expertise, we can do so much more together.
When we think about predicting the future needs of the health service, we are often only able to look at people based on their medical condition in isolation, unaware of the wider determinants impacting on that individual and their community. Here reside the real reasons they are ill and indeed the meaningful solutions to their problems.
Working together with wider partners, bringing our data together with common shared purpose and ‘language’, the population health management approach brings us closer to a future where we are able to make a real difference to both communities and individuals and helping to predict how the NHS needs to adapt and plan in the years to come.