Module three: Creating new models of care through new data

Critiquing data and measurement approaches, generating new insights, and building data and measurement skills.
Dr Rupa Joshi, Louise Wheeler

12 September 2023

PCN leaders on the South East PCN Leadership Development Programme found activities on module three useful to better review papers and question data.

How do we know that a change we have made has led to an improvement? Data can give us that reassurance, however it can also be biased. In primary care, we do not always have the tools, the understanding, or the resource to be able to measure effectively. When we mention data it’s all too easy to feel scrutinised for performance, but data can be used to measure for improvement.

How do we decide if the data we are viewing are the right data? and how do we decide that the data show improvements for patient care? This can sometimes feel overwhelming, but our participants gained confidence within the data sphere by the end of this module and have been exploring the potential to develop new models of care through new approaches to working with data within their primary care system.

“Data analysis is a very powerful tool for people in terms of seeing patterns, seeing things happening, questioning, and then wanting to do something about it. So, I think it's fantastic to have a session like that and I found it very informative and challenging.” PCN leader and programme participant.

The impact of the learning for our PCNs

The module offered the opportunity to explore variation of patient experience when interacting with reception teams.  It helped us to consider the variation that our patients have in equity of access to our appointments, including our frequent attenders, thinking about continuity of care and the value of utilising the multi-disciplinary team.

In reflecting on this at a focus group, one PCN leader said:

"….it was incredible to feel what it was like to be a patient trying to get an appointment …I don't think like that because I'm a clinician, but actually I do need to think like that.” 

It has been difficult for general practice to gather data to show our activity. We are getting better at this now with advanced telephony and other platforms for demand and capacity data. We are becoming more adept at working together with our secondary care, community care and ambulance trust colleagues as members of a system and looking at demand overall, and we need to continue to build this capability.

One participant stated:

"How to pick out the golden nuggets from data, and then express them in such a way that it's easy to understand for patients and politics to show that we are actually working extremely hard and we’re seeing as many patients as we ever had, is key.” 

“We are in the process of using connected care data to segment our patients into red, amber and green as a tool to help with continuity of care and improving equity of access. Red patients would be our frequent flyer cohort and those with complex medical needs who would benefit most from continuity of care. The very concept of using these data has stimulated thinking around solutions and working at scale, proactive care planning and using our ARRS staff in a more productive way. There has now been a move towards 15-minute appointments as we have recognised that our patients are returning less often with a more detailed review. I am hopeful that data will show impact on patient outcomes, as well as staff retention.” Dr Rupa Joshi.

PCN leaders on the programme have built capability to explore how building new models of data can support design within at-scale solutions such as hub working, integrated neighbourhood teams or virtual wards, or use the skills of the personalised care team for preventative care and community outreach health inequalities projects. We believe that focusing on personalised proactive care will reduce our future frequent attenders. Data will help us demonstrate the impact of this approach.

Training and development for leaders as well as digital and transformation leads

The value and potential of digital and transformation leads (one of the ARRS roles) have been recognised across primary care in the south east. This is demonstrated by the number of south east regional initiatives available (in addition to any specific ICB support) to help both PCN leaders generally and digital and transformation leads specifically, to develop digital and data capability and networks. These include a new NHS-England-funded digital and transformation leads leadership programme, and the NHS Confederation digital and transformation leads forum.

However, as PCN leaders explored their own capability needs in data analysis and the use of business intelligence tools, it appears more could be offered on the detail and on specific systems. One PCN leader shared that "having access to toolkits, knowing where to find them and how to operate them would be a lot of benefit.”

Another leader expanded on this:

"There's all sorts of dashboards everywhere that we can use. But … for example, I went to a training session on the SHAPE Atlas tool because I thought this looks fantastic. We can identify stuff at postcode level, but it was so complex, and the training was so quick that I came away feeling more frustrated than when I actually started. So, I think we need training around the tools that can allow us to do the jobs that we need to do with population health."

PCN leaders shared the wider shifts in thinking they had by developing the mindset to question variation in data, identify blind spots, and the real importance to understand the impact of how data is displayed on our decision-making.

One participant remarked:

“It’s not just how to access business intelligence data, but how to express it both to practices and to patients through patient participation groups.... And also, how to use business intelligence data to apply to future change and development."

In understanding our data at primary care level, we are able to develop strategies for the most effective use of population health management data, and are able to present these data to influence commissioners to support our projects and help tackle common PCN leadership challenges.

PCN leaders shared that building capability to reflect on data enables more openness to thinking of alternative solutions and that it has encouraged them to have more frank, open and honest conversations that can open new possibilities and opportunities.  The power and opportunity of having interoperable data, that can be shared to bridge the secondary and primary care interface, that can be shared with partner organisations to help develop community level shared purpose and stronger collaborations, to move forward together, looking upstream to help our communities is a vision that all support.  And this needs investment.

Dr Rupa Joshi is a GP and clinical director for Wokingham North Primary Care Network and deputy chair of Berkshire West Primary Care Alliance; clinical adviser for NHS England’s Primary Care Transformation team; chair of the Workforce and Estates Design Group at NHS Confederation’s Primary Care Network; and clinical adviser for learning and development for the South East PCN Development Programme.

Louise Wheeler is the primary care leadership development consultant at the NHS Confederation.