Dr Ian Jackson, Medical Director and Clinical Safety Officer at Refero, shares his thoughts on the reality of the Health Systems Support Framework

According to NHS England, HSS Framework was created to help NHS organisations “access support services from innovative third-party suppliers at the leading edge of health and care system reform.” Population health management is an approach aimed at improving the health of an entire population and improves population health by data-driven planning and delivery of care to achieve maximum impact for the population.

Sounds very grand, but what is the reality on the ground – is something like this feasible on a scale of a sustainability and transformation partnership (STP) or even something smaller? The overall idea being we look at population data and use interventions to keep patients out of hospital, empower them to look after themselves.

Population data to keep patients out of hospital

Let us consider some real situations. The reality is we know the care homes with frequent flyers to hospital care, those care homes that either have higher acuity patients or lack the skills and confidence to look after someone who is sicker than normal. These are known both within secondary care and primary care and there are interventions that can make a difference.

  • Patient and drug reviews by a visiting pharmacist can reduce drug interactions and review the extensive medications many elderly people are on.
  • Provision of regular support and helplines be that from primary care or secondary care.
  • Hospitals are trialling provision of support via telehealth.

Frequent A&E flyers

What about frequent flyers direct to A&E or via the ambulance service? Again, these are well known in the Ambulance Service and secondary care and are flagged up within their systems. Indeed, frontline ambulance service personnel can recognise these individuals as soon as their name appears for an emergency pick up!

However, where are the headroom to provide support to these patients to avoid admission? Each will require considerable time to review, and an attempt to come up with a care plan that avoids repeat admissions. It is a brave person that would say they know the answer to stopping these repeat attendances.

Similarly, given the information flow to GPs about each attendance, they are well known in primary care. Again, where are the headroom and the stimulus to provide support for these individuals?

Sharing data

So, will the sharing of data across a larger population of say a STP and then the use of data tools to manage and interrogate the data lead to breakthroughs in the potential care for a population?

Sadly I’m cynical and see a huge industry being created where extensive investment in business analysis and data reporting tools will increase costs, but show little gain for patients.

We know that we need to get better at multiagency working with systems that allow genuine linking of at-risk patient groups to a multiagency care team. Allowing secure two way messaging between a patient and the caring team on a 24/7 basis with the ability for messages to be handed off to the most appropriate team member to deal with – be that a community worker, district nurse, GP, specialist nurse or even consultant.

Add in the ability for teleconsultation and perhaps we start to get to point where we can start to genuinely help support patients at home. The next stage is to pull in ‘soft data’ such as movement profile in the home, use of appliances etc. and then you can actually offer an active monitoring system.

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Medical Director and Clinical Safety Officer
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