Thinking Differently Together - Population Health Management - April 2022

Suffolk and North East Essex Integrated Care System (ICS) 1. Introduction Online event Wednesday 6 April 2022 ‘Thinking Differently Together’ about… How Population Health Management and IntelligenceLed Health and Care can make a difference to everyone Population Health Management (PHM) is a technique that uses data to design new models of proactive care and deliver improvements in health and wellbeing which make best use of collective resources. It can help us understand our current health and care needs, and predict what our future needs may be, so we can take action in tailoring better care and more personalised support, design more joined up and sustainable health and care services and make better use of public resources. It is how we use historical and current data to understand what factors are driving poor outcomes in different population groups, and then design new proactive models of care which will improve health and wellbeing today, as well as in the future. This could be by prevention, or, where this isn’t possible, by improving the way the system works together to support people. This event follows our second programme of support from the National Population Health Management Programme, where many more primary Care networks have had the opportunity to use their data to identify selected local population cohorts, and work through the real time application of advanced analytics and intelligence-led care design. It has been enabling the building of collective capability across commissioners, providers, Primary Care Networks (PCNs) and community partners, to make informed data driven decisions that will make a positive difference to people’s lives. The event provided an opportunity for colleagues and teams across our system to share the work they have been doing and insight gained through putting Population Health Management into practice. Zoe Billingham, Chair – Norfolk and Suffolk NHS Foundation Trust 1 | Suffolk and North East Essex Integrated Care System

2. WHY Population Health Management and Intelligence-Led Healthcare is so important What Population Health Management means to me - A short film Tristan Childs – Public Health ‘So currently as a as a public health researcher, analyst, a lot of the work I do is around answering relatively straightforward questions, analysing individual data sets and part of the challenge, the reason we answer a lot of simple questions is we don’t actually have the data sets to be able to answer more complex questions. So I think probably I would hope and envisage that one of the key changes that population health management bring is that by being able to work with linked data sets and I’m talking about linking together data from primary care and secondary care and wider determinants from different organizations, that would be able to answer some of those more complicated questions. I don’t envisage that the process of that would involve working across multiple organisations working with different specialists from those organisations and working in a broad and multidisciplinary team to answer some of those interesting projects. I’d say the real power of population health management is in enabling us to have evidence-based action that’s driven by the data. So I think probably the role of analysts will be very important in this process because analysts will be the link between the data and the decision making. So I think there’s a lot of opportunities here from I’m talking selfishly from my perspective as analyst, there’s a lot of opportunities for professional development and for analytical creativity whilst working on some of those more interesting wider projects.’ Lisa Andrews, CVS Tendring I think that actually finding out, on specific cohorts of patients, what is going to be most beneficial to them, is going to make an absolutely huge difference. The project we’ve been working on with a surgery in Clacton is around people with mental ill-health and finding support for them and helping them to access the things that are going to make a difference to them – whether that’s employment, physical activity, connecting them to local community groups, and obviously, if you can pin down the people that have those needs and actually provide them with something very specific, I think that is going to make a huge difference. Working in partnership in that different way with our GP surgeries and with our communities and our community groups is hugely beneficial to everyone involved. Thinking Differently Together | 2

Dr Susan Pickford, GP ‘Population Health Management is something I’ve recently become interested in. it’s really brought home to me how important that understanding of our community is, in terms of developing and providing a service to our patients that is focused on their needs and also delivers a service for the right people, at the right time. We often tend to focus on the problems, especially as GPs we tend to firefight and tackle a problem as it comes up, but I think I’ve started to understand that if we can understand more about why things are developing, why these problems are occurring and what is actually going on for our patients at the beginning of the story, then we’ve got a much better chance of actually preventing ill-health, and becoming better at getting on board to do that. I think there is that the old saying that prevention is better than cure, and population health is a really good way of looking to identify the needs of a group of patients – obviously we need to focus on the individuals as well – but by understanding where problems might be starting to develop, we can look at how we can prevent that happening – and it makes sense from a patient point of view, and it makes sense from a financial point of view. I think understanding the needs of our population, understanding where the problems are, and developing earlier on, things where we can provide help and support before they become bigger problems. If we can understand the needs of our population then we can focus our help and the treatment that we give specifically to those patients rather than treating the population as a whole or treating the problem rather than actually addressing the underlying issues that cause the problem in the first place.’ Dr John Harvard, GP I have been a GP in Saxmundham for over 35 years and cannot bear the thought of spending almost all my career prescribing drugs and walking away without making any enduring impact. If I really felt that they cured people, then it would not be so bad but the major issues of the day relate to mental health and not physical disease. This is why I am ploughing our own furrow by directly employing our own Practice RMN for six sessions a week. Anxiety, depression, self-harming, alcohol and drugs are all symptomatic of society and are peaking nowadays. There is little space for ordinary life and ordinary failings because there is so much perfection on polished air brushed social media platforms that all viewers feel a failure. There is no time for ‘meaningless’ chat because everyone is busy and driven to performance targets. Mums and Dads both work and sit in front of the TV exhausted so family conversation is limited, and communication is more through screens than real life. Green Light Trust introduce distressed people to the calm and non-threatening ways of nature. Participants work with each other doing simple creative things and unite as a team to make a fire and prepare and cook a meal that they then enjoy together. It allows people to stop, think and look around and see what really matters. They ‘stop the world’ for a few hours so people can get off and enjoy the natural environment for a short spell before getting on again refreshed with new and enduring insights to face their own problems. The help that GLT give is a catalyst to empower people to help themselves. Now that is the only sustainable solution on the menu...and beats drugs every day. 3 | Suffolk and North East Essex Integrated Care System

Tom Brown, Greenlight Trust ‘As a charity, from the evidence that we have had previously, we know that we support people in the lowest 5% in the population, in terms of wellbeing. In many cases, those are the ones that are the high volume users of primary care services. Working more closely with the GP surgery has allowed us to identify the people who are really going to benefit from our services, identify a way of working with them, but also identify the best support that we need to put in place – and that is really the key part to what we do – putting the support in place that allows the individual to engage and really meet all of those unmet needs that has caused them to come onto one of our programmes. Overcoming a lot of anxiety, and issues like transport initially, but we get a much more holistic overview of the individuals that come onto it, which I guess, is why we get the outcomes that we do.’ Jarrad Murray, Clinical Commissioning Group, Business Intelligence ‘Population health management has changed the way that I work in a number of areas. Firstly, it has broadened the number of individuals and services that we work with and converse with to be able to identify certain areas, and work on certain pieces of activity, so that’s not only just the acute providers, but we’re also looking at conversations with the community providers with GP practices, social prescribing and pharmacists. It’s really expanded the sort of reach that we have within the organization. I think it’s also changed the way that I work by broadening my knowledge of the overall system of the health economy. So, as I say, not only just within the acutes, but understanding how social prescribing works. It’s also given me the opportunity to work with a much larger group of data sets with a much wider remit of information within it. This is then helped with population health management to enable us to identify not only the health barriers or particular concerns that are going on within the environment and the Community but also to then try and identify where there are contributing factors - So whether that be within education, or within socioeconomic factors. The joining up of all of this linked data has been really eye opening and is a real challenge going forwards. I feel the value of working in this way is not only the collaboration between various different systems where we can learn and identify from strengths of each other - So a GP will have a different focus to a pharmacist or one of the Commissioners. It helps us to view every side of the problem that we’re trying to face and then be able to identify and consider all the various different avenues that we can take going forwards. I also think that one of the benefits of working in this manner is that we can actually try and make a difference for the population that we’re caring for, so not only are we going to be considering the potential outcomes for these patients, but it also gives us the opportunity to look on the other side - what are the various different markers and triggers that we can see? So actually, is there something we can do to almost do a preventative measure going forwards and maybe eradicate some of the problems that we’re seeing as being fairly prevalent across our society.’ Thinking Differently Together | 4

How predictable is the unpredictable? Nick opened by explaining how the ambulance service is quite a reactive service – when people call 999 there is limited pre-cursory information to provide to patients. Falls in the community constitute about 25-35% of all ambulance calls within the UK. The infrastructure and funding into trauma care, which is only 1% of the workload, yet a quarter of all calls are to injured and noninjured fallers, predominantly over the age of 65; this is a tremendous amount of people to have a direct input to. Each year, 400,000 of these are taken to Accident and Emergency departments; and of those 14,000 will die due to post-hip fracture, poor recovery, isolation. In addition, there are significant risk factors of osteoporosis for women over the age of 70, with 50% of women suffering an OP hip fracture by their 70th birthday. After a traumatic fall 50% of patients cannot live independently post-surgery. We need to be a bit more proactive in terms of our care: We know that these people will fall, so what can be done as an ambulance service to prevent that? There are three real reasons why people fall: There are physical factors, extrinsic reasons, such as steps and environmental factors, and there are behavioural factors such as alcohol, activity, footwear, and social isolation from a first fall. There is a very simplistic assessment tool for fallers - a system called SPOC (single point of contact), is used, where all fallers over the age of 65 are referred – it covers the simple biometrics of age, location of the fall, and if they are on 4 or more medications. It doesn’t cover things like diuretics, antidepressants, or drugs that we know are linked into higher risk falls. Most falls come down as a category three call, which should be responded to within 120 minutes – which already puts a pressure onto the ambulance crews regarding the risk of ‘long lie’ issues of patients who are on the floor for more than an hour, which include rhabdomyolysis, acute kidney injuries, and pressure sores. Covid-19 Nick Williams, East of England Ambulance Service NHS Trust (EEAST) 5 | Suffolk and North East Essex Integrated Care System

has impacted on the service greatly over the last two years, where a lot of the calls are taking up to 6 or 7 hours to get to, so if we can try and prevent people from falling in the first place it can help negate the risks of them lying injured for long periods of time. Nick gave an example of a 69-year-old man in Colwyn Bay, that fell in the street and waited 10 hours for an ambulance that was simply due to pressures from acute hospitals and off-loading times. This is the reality of the situation, and for relatively young people that have waited – if we could prevent them falling in the first place this terrible experience is negated. Not everyone can be prevented from falling – there will be patients who have increasing risk factors; diabetics, Parkinson’s patients, stroke patients, those with limb amputations, all have increased risk of falling. We know that once admitted to hospital, the decline in their health is rapid: 2-5% of muscle mass is lost in the first 24 hours in hospital. Of those patients who go into hospital, only 30% return to their normal baseline of activities of daily living within one year. Those who go into hospital and have catheters, the increasing risk of their catheters failing is 60%, and being over 75 years increases the risk of having a catheter in the first place. The increased risk factor just of the social care being required is owing to a decline in walking ability that occurs within 2 days of admission; 72.9% of patients assessed as able to walk – did not walk at all prior to discharge. If people fall, they are going to lose their independence and have a continued fear of falling, but we can do something about this through a holistic approach. If we can try and capture details of the people that fall at the time they fall – more biometric, holistic and biopsychosocial - capture what medications they are on, what their housing situation and home environment is, their social interaction, mobility and support networks, Nutrition, continence and personal care, whether they are physically active, do they have a vision problem such as glaucoma and cataracts affecting depth perception, checkup what type of fall they’ve had and its location, it will give us a bigger picture to work on with primary care networks and hospitals and by working together, to try and reduce falls. The impact on patients • Frustration at losing their independence to carry out daily activities • Fear of falling again • Distress resulting from uncertainty and anxiety in life after suffering a fallrelated injury • Embarrassment from injury and/or usage of walking aids • Loss of self-esteem due to an inability to take care of oneself after falling • Loss of independence • Changes to daily routine • Financial cost of hospitalisation, handling aids, carers, mobility, taxis etc • Loss of social contacts due to longterm immobility, lack of family support • Decreased quality of life • Fractures, especially at the hip or wrist • Pain or discomfort • Medical conditions/health problems due to prolonged immobility • Difficulty or inability to move around independently, especially for long periods of time • Unsteady walking pattern Thinking Differently Together | 6

3. HOW Population Health Management canmake a difference The importance of Population Health Management as part of the vision for ICSs The population health management approach is aimed at improving the health of an entire population: Improving both the physical and mental health outcomes and wellbeing of people, whilst reducing health inequalities within and across a defined population. It includes action to reduce the occurrence of ill-health, including addressing wider determinants of health, and requires working with communities and partner agencies. This is important because 80% of what makes people healthy and happy isn’t health care. By looking at the pre-cursors to health decline for an individual, such as whether you can do your housework, can you cut your toenails, can you walk to the shops, can you put out your wheelie bin – these things offer signals to whether there is deterioration in health. From the 1st of July the four core purposes of Integrated Care Systems (ICSs) will be to: improve population health and healthcare, tackle unequal outcomes and access, enhance productivity and value for money, and help the NHS to support broader social and economic development – so 50% of how an ICS works is about looking at improving the health and wellbeing of its population, and using population health management as a mechanism to do that. It helps us to really think about equity, rather than equality, which is why the NHS was established in the first place. This is a big change in the operating model of the NHS and could enable keeping people happier and healthier for longer. There has been a huge amount of new policy published, and all of it talks about population health management: From the Long-Term Plan which has a major focus on health inequalities and how to use population health management, right down to the latest planning guidance. Core 20 Plus Five is something to use as a framework of focus but the population health management part of that is understanding the ‘plus’ and what that means to your local population. Bevleigh Evans, Head of Population Health Management at NHS England and NHS Improvement (NHSE/I) Juliette Glenn, ICS Development Lead NHSE/I East of England 7 | Suffolk and North East Essex Integrated Care System

There is a very clear ‘ask’ for population health management (PHM) in ICSs as all systems need to have a PHM capability plan – this is essentially the ‘roadmap’ that has already been produced by systems. By the spring of a next year a linked, person-level data set across the system will be required, this will evolve from the current situation where it is for healthcare only, and ICSs may need to think about how they bring their resources together for data analytics. There are four building blocks for PHM: Infrastructure, Intelligence, Interventions, and Incentives. Juliette gave an example of how population health management can be used to drive the vision of a system based on the example of Herts & West Essex ICS who produced the diagram below. An ICS has four core purposes: • Improving outcomes • Tackling inequalities • Enhancing productivity • Helping support broader social and economic development Ask Deadline Document Comments All systems to have PHM capability plans April 2022 Design Framework All systems that have completed Wave 2 PHM DP should have a PHM Roadmap and I will confirm this. Those in Wave 3 pragmatic as they will be working towards them and have them by July 21 Every system should have in place the technical capability required for population health management April 2023 Planning Guidance This means - Linked person level data (system linked dataset) - Population health platform that allows for segmentation and stratification - Systems are encouraged to work together to share data and analytic capabilities Integrated care strategy December 2022 Design Framework Build bottom-up from local assessments of needs and assets identified at place level, based on Joint Strategic Needs Assessments. We expect these plans to be focused on improving health and care outcomes, reducing inequalities and addressing the consequences of the pandemic for communities. Thinking Differently Together | 8

Using population health management enables an ICS to achieve all of these four purposes. The foundations are the infrastructure: it needs high quality data that is shared in the right way (information governance) which is developed into linked data at a person level. It needs foundations of analytical tools (e.g. that enable segmentation and risk stratification etc) skills and processes and also the development of PHM leadership across the system. Building on these foundations of infrastructure, intelligence and insight enables you to build the pillars: to understand and describe the needs of your communities (understanding of the population’s needs at different levels both at different geographies and for different population groups); it enables you to support the delivery of high impact interventions by using research and best practice to improve lives through clinical and care changes. It enables you to monitor the impact (you can evaluate and assess the impact of these changes and whether they are effective); and you can support new financing models and incentives as levers to make the changes happen. These pillars help the delivery of improved outcomes and better value for a system. There are a number of support options available through regional support: These include • East of England PHM Analytical Skills Development Network, which brings together the analytical workforce working directly or indirectly on PHM across settings and systems. • PHM Community of Practice which is open to all showcasing local work or relevant national tools and practices. • A repository of network information on FutureNHS platform, which contains News, Calendar of meetings and events, Training opportunities and support offers, Case Studies, Knowledge Exchange Archive, Analytical Resources and Tools, a Knowledge Library and Links to other regional networks https://future.nhs.uk/populationhealth/ view?objectID=21472016 The FutureNHS platform also allows access to B2H interactive dashboards that display aggregated outputs, i.e. not patient level. Data can be accessed by external NHS organisations such as commissioners and providers. It allows users to quickly see key information about their local populations and understand drivers of future service needs. This information will be invaluable in the design of future services and as such inform negotiation of fixed payment to support this delivery. These dashboards are available at https://future.nhs.uk/ connect.ti/NHSEPaymentsystemsupport/grouphome . Please note you will need to join NHS Futures and may need to request access. 9 | Suffolk and North East Essex Integrated Care System

Atrial Fibrillation – A population health management approach Atrial fibrillation is an important population health problem. It is a condition that affects heart rhythm by causing part of the muscle to wobble, rather than to beat – because of this, blood can pool and form blood clots, causing a number of different problems but the most well-known, and the one that we are most motivated about trying to prevent, is stroke. Atrial fibrillation (AF) has been on the radar as being a very important risk factor for a long time, but it has always been a challenge to find the right ways to identify people who have AF if they are not symptomatic. There has been a lot of research related to the topic and there are current research trials running; the problem is that it is inefficient – like searching for needles in haystacks – so this work set out to see if something different could be done through using clever data analysis and digital technology. There are some useful statistics about AF. The prevalence of AF has been recorded for some time in primary care, through the Quality and Outcomes Framework. There are also fairly reliable estimates on what the real number of people with AF is likely to be. Every area in England has a graph that shows where people have been identified with AF, and the percentage of people in those communities that are likely to be undiagnosed, and therefore, unprotected against the stroke they are at risk of having. We know that 25% of strokes have AF as their primary cause. Dr Anne Swift got involved with a project that has been running across Suffolk & North East Essex with the Eastern Academic Health Sciences Network (EAHSN). The principal of the project Dr Helena Jopling Associate Medical Director, Future System Programme, Consultant in Public Health Medicine and Public Health Clinical Lead, West Suffolk NHS Foundation Trust, presenting on behalf of Dr Anne Swift, Public Health Consultant, West Suffolk Foundation Trust Thinking Differently Together | 10

was to test an application called Fibricheck; A medically certified app (CE Class IIA, FDA approved) capable of the early detection of heart rhythm disorders, such as atrial fibrillation, using a smartphone or smartwatch. It uses the smartphone camera to take your pulse and detected an abnormalities in heart rhythm. The App uses a technology called photoplethysmography (PPG): With each peak, the PPG measures the dilation and relaxation of the blood vessels as a result of the electrical pulses of the heart. The technology has been validated as effective in detecting abnormalities in heart rhythm. The goal with the EAHSN was to try and design an all-digital pathway. Identifying people with AF is usually done through opportunistic case finding by taking a person’s pulse, whilst they happen to have a routine contact with a health professional such as in a ‘flu clinic, Covid vaccination clinic or having an NHS healthcheck. The intervention was trying to find a way of supplementing those approaches with a digital pathway that could be done at scale. Using a linked data set that combines acute hospital data and community services data, people who either do, or don’t, have AF diagnosed can be identified in their medical records. If they have AF, it can be identified whether they are being treated or not. For this purpose, the intervention identified people who don’t have a record of being diagnosed with AF and aren’t on an anticoagulant – the preventative treatment used to try and avoid a stroke. The people on that list are then sent a text message promoting to them the Fibricheck App. In West Suffolk a text messaging service called ‘DrDoctor’ is used for this. In the text, people are invited to have a free, seven-day license for the Fibricheck App. Those that accept the offer are sent the license for the Fibricheck App which they can download onto their phone. Those that decline are not contacted further, however, those that either don’t respond or that say they are unsure, are contacted again in seven days to have a further chance at taking up the offer. Ideally then, the person would download the Fibricheck App onto their phone, and they are advised to check their pulse with it twice a day for seven days. If the App identifies a ‘red report’ which indicates a likely case of AF, that information is passed to the Cardiology team at West Suffolk Foundation Trust (WSFT), and if it looks suspicious for AF, the person is sent in the post a Ziopatch (a small, unobtrusive ambulatory cardiac monitor patch) and a blood pressure monitor. These enable them to measure heart rhythm and blood pressure themselves whilst they are at home and then return it to the team. The Ziopatch company analyse the results for WSFT and anybody that looks like they need a clinical review because results indicate the chances of them having AF or another problem are high, will have either a telephone or video consultation remotely with the hospital clinicians. It is still fairly early days, and it is still a very novel approach where there has been a lot of ‘test and learn’ to ensure that the pathway worked, was 11 | Suffolk and North East Essex Integrated Care System

safe and any unintended consequences were understood. One of the really exciting aspects is that because of the way the analysis has been built in the data platform, the people who are at highest risk of stroke can be identified if they have undetected AF, because of the nature of their other risk factors. This can be done using a scoring tool called the CHADSVASc score, that provides a percentage likelihood of having a stroke if you have AF, and this is determined by other characteristics that a person has. Using this method, the team has been able to identify people at highest risk, so the free license for the Fibricheck App have gone out to those people first. As at the middle of March about 1500 text messages had gone out – of about 1500 people, 202 have activated the licence, 162 have performed at least one measurement; of those, 12 cases of AF have been detected and are currently in their investigation pathway, one of which has now completed the pathway and is on preventative therapy. This has since been scaled up, and around 4,500 people have now received text messages, and more cases are very likely to be detected as a result. What is particularly exciting about this is that it is a far more efficient way of identifying people at risk of a serious illness, to allow early intervention: It has a high-yield rate (7.5%) as compared to opportunistic case-finding for AF through other settings, which has a yield rate of 1% or below. Thinking Differently Together | 12

The Role of the Voluntary and Community Sector in Population Health Tristan outlined the role of Community 360 – the Council for Voluntary Services (CVS) for Colchester. Like many CVSs they champion community voluntary action in their local area; workstreams include being the district volunteer centre, provision of social prescribing, Community transport, Family support services, community capacity building, training and fundraising. Community 360 has been involved in social prescribing for about 8 years, having started by working out in the community with a focus on early intervention and prevention, to support people in the community to prevent them needing a doctor. As the services have developed there are now dedicated roles and staff based within both primary and secondary care. Social prescribers speak to approximately 5,000 people each year (up to about 8,500 during Covid), offering access to, and information about, local voluntary and community groups. Community 360s social prescribers are working with a very wide range of services and settings, including Primary Care Networks (PCNs) and GP practices, East Suffolk and North Essex Foundation Trust (ESNEFT), Essex Partnership Trust, connecting people with clinical advisors to activities within the community, and some specific pieces of work on end of life with St Helena Hospice. Community 360 have worked with several PCNs on their PHM projects and participated in action learning sets on the defined cohorts of patients. These have included women over 30 with severe mental illness, over-75-year-olds at risk of falls, children between 8 and 16, and young people from areas of deprivation, between 13-18 with anxiety/phobia. A lot of the CVS work and focus is on developing infrastructure and capacity in neighbourhoods and places – examples are things such as funding community and voluntary sector organisations and developing neighbourhood level activities. There are two strands to this: one is on the social prescribing role – talking to and connecting with people and referring them into different services; the other is on how they work with neighbourhood assets to try and meet some of these needs. There are many advantages to engagement with the community and voluntary sector, and covid shone a particular light on these. A lot of it comes down to opportunities in ‘place’: Population health management from a neighbourhood perspective recognises that there are different scales – many opportunities available Tristan Easey, Deputy CEO, Community 360 13 | Suffolk and North East Essex Integrated Care System

for people are ‘hyperlocal’, groups activities and services that people have really great contact and relationships with people on a day-to-day basis. Local intelligence is really important, and local organisations feed back regarding demand and help the understanding about people, their neighbourhoods and place they live. This in turn leads to more peer-led opportunities: Many people with lived experience provide support and these are led by volunteers with personal knowledge that want to support people who have similar experiences. The voluntary sector can be incredibly adaptable and flexible; innovation comes quite naturally to many of the organisations, particularly the smaller ones who are often very adaptable. As a local CVS, there is the ability to support specific activities through grants, awards and practical help. An example of this is the recent work with a PCN on the falls prevention pathway and referring people into specific interventions. Support can be given through social prescribers linking in with pathways of specific services or facilitate working with groups to put on strength and balance sessions local to that GP practice. Positive results that have been seen locally have been in improved access to community pathways through social prescriber’s knowledge of what is available. They also contribute to prevention and earlier intervention, and one of the big strengths of the voluntary and community sector is in its flexibility and responsiveness, that gives an ability to work on bespoke services or to scale services up or down as necessary. The biggest strength, though, is perhaps in the community capacity building and the ability to help people to self-manage, selfsupport and able to access any wider support they may need on an ongoing basis. Thinking Differently Together | 14

4. WHAT Difference Population Health Management can make in Primary Care 4a. PHM Projects from Primary Care Networks – A Focus on Complexity Ranworth PCN We have selected a cohort of 118 people aged between 20-49 years, of middle complexity (2-4 acute/chronic conditions) who have a mental health flag and are high utilisers of GP services (15+ encounters in 2020/21). These are patients registered in Clacton Community Practices and Ranworth Surgery. We think we can help this cohort by signposting them to appropriate support organisations, by social prescribers and link workers to help support generally and prevent further deterioration of their health and wellbeing. We also think we can support them with employment prospects through access to local services/organisations. What we have learned • The process has been enlightening to all those who took part • It highlighted the complexities and co-morbidities faced by some of our population • Our PCN suffers from high levels of deprivation which is atypical of other areas • We should have involved a social prescriber and care-coordinator right from the start • We had representatives from organisations at a management level, but “ground level” input can be powerful • Limited input from clinicians at practice and system level due to workload pressures • It has been difficult to get everyone “around the table” to have effective discussions due to work pressures • We did not realise the positive point that the future care of our population could be managed by bringing a wraparound service and implementing a MDT approach (health, social care and third sector organisations) to bring about better outcomes for our population. We need to bring this model to life to make it work • Ideally, we need a PHM champion within the PCN to keep momentum, but no one seems to have time to commit. • Our roadmap: We have identified our top 10 people from the chosen cohort and going to commence MDT interventions from April 15 | Suffolk and North East Essex Integrated Care System

North East Coastal PCN We have selected a cohort of 96 people, aged 75 years and above, not living in a care home; with a history of falls, frailty and have 2 or more long-term conditions (IHD, hypertension, diabetes, COPD, asthma or flagged for polypharmacy). We think we can reduce or prevent further falls/condition deterioration by reviewing the factors (biopsychosocial factors) that can be optimised for the individual patient, e.g., polypharmacy, condition management, environmental and social support factors; and improve their access to available services. Our patient stories: Patient A • 86-year-old female, lives with husband; has family input but not sure how supportive • Multiple comorbidities: Irregular pulse, HTN, diverticulitis, hypothyroid, hiatus hernia, DVT, fracture pubic rami, bowel issues, haemorrhoids UIT, cellulitis • Has had 13 consultations in 2 years. On review of notes, it seems there are list of issues they want addressed on any consultation • Meds reviews carried out: polypharmacy (11 medications) and blood tests are up-to-date • Referred to social prescribing team to establish what her unmet needs are; as clinical care has been optimised as best as possible • What are her biopsychocosial needs that can be addressed through local services? Patient B • 91 year old female, new diagnosis of dementia • Other medical conditions: CKD 3, poor sight, hypothyroidism • Lives alone, has access to village support as family live 80 miles away • Fairly independent and wants to maintain that as much as possible. Family happy with her choice • Has short-term memory recall, MCI not confused • Referred to social prescriber/occupational therapy, to asses what support is required to maintain independence • Mixture of social, environmental and agency support/services locally? The value of what we are doing is great, as the data shines a light on the population but full clarity can only be gained through local knowledge and knowing your patient at “ground level” – Dr John Havard & Suzie Southey Thinking Differently Together | 16

North Colchester (Mill Road Group) PCN We have selected a cohort of 46 people who are in the high complexity segment, have obesity and are aged 30-55, and we think we can approach these individuals with information on what is available, who they can contact and invite them to become involved; with the aim of improving their health and well-being and reducing their risk of developing further health conditions, such as Diabetes and Hypertension Barack Lane & Ivry Street PCN We have selected a cohort of 76 people who have COPD and are aged 30-59 and attending A&E (for any reason) between 1 and 5 times per year, and we think we can adopt a multidisciplinary approach to address the interaction between mental health, smoking and other comorbidities. We think that one of the drivers of unstable health could be due to deprivation 17 | Suffolk and North East Essex Integrated Care System

4b. PHM Projects from Primary Care Networks – A Focus on Prevention Deben PCN We have selected a cohort of 115 people age 20-49 who are obese and have a history of smoking, but are not diagnosed with hypertension and with very low contact with primary care and we think we can try to encourage/support them to engage with the health/care services and with a view to reducing risk of future ill health. What we have learned • PHM is a new idea to most involved. Its academic underpinnings are unclear currently. • How does PHM activity integrate with current Public Health work? • Working virtually across different groups of people/practices is extremely difficult. • The manpower resource needed to undertake new work has not been considered – what activities are to stop in order to divert resources to PHM projects? • The process of identifying patients for the project is exceedingly complex, involving multiple steps which have baffled some of the participant practices. • It would be much easier to undertake projects at a single practice level rather than across a group of practices. The more practices/professional groups are involved, the more complex the project is and the harder it is to make any meaningful progress Thinking Differently Together | 18

East Ipswich PCN We have selected a cohort of 108 people who are 30-59, obese and in pre-diabetic state (raised HbA1C recorded in last 18mths) and we think we can improve the individual’s experience of health and care services (not telling story repeatedly), empowering people to take ownership of their health & well-being and feel motivated to engage with services - and we think we can make it easier for them to do the ‘right things for them’ reduce prevalence of comorbidities through supporting individuals to live healthier lifestyles and learn from them. Forest Heath PCN We have selected a cohort of people from Forest Surgery with moderate risk (499 individuals) of a hospital admission within the next 12 months, who have no identified long-term conditions and are aged over 65, living within middle deprivation deciles (4-7) (38 individuals) and display clinical indicators of being at risk of frailty in the future. We think we can identify frailty risk factors and prevent the onset of or an episode of frailty in this group by intervening early with proactive care and preventative interventions. 19 | Suffolk and North East Essex Integrated Care System

Interventions • Health education - care home/nursing homes - carers - GP dedicated clinicians for each care home - upskill – MDT inputs into homes • Nutrition – protein supplement • Vitamin D supplement • Frailty tools – selection (CGA) • Integrated MDT • Targeted frailty information pack • Targeted health promotion • Health improvement e.g. stop smoking • Exercise – ACL patient pathways • NHS health check • Social prescribing • Community connection e.g. volunteering or befriending • General health promotion Indicators • Frailty syndromes – falls, incontinence, cognition, polypharmacy, reduced mobility • Frailty assessment tool outcomes in combination with clinical assessment • Unintentional weight loss, vitamin D deficient, poor oral health • Higher healthcare service use within 6-12 months: - hospital admissions, - visits to A&E - visits from community nursing or GP • LTC & comorbidities (diabetes, asthma, CLD, cancer, hypertension, stroke, kidney disease, arthritis) • Age 65+ • Gender – female • Deprivation, socio-economic status, housing tenure • Living alone, having a carer/support activities for daily living • Modifiable factors – smoking, obesity, sedentary End of Life Very high active risk High risk and rising Mild to moderate risk – potential to rise Low risk – most of the population Our patient story: Frailty isn’t inevitable – it can be prevented! It doesn’t have to fall to the GP to manage people experiencing frailty, especially at onset. Opportunity to let people know what to do, other than ‘go to the GP’ if they feel like they’re deteriorating. Themes from patient conversations: Mental health – anxiety and worry Still working full time – working well or unwell? Transport Flagging local resources and literature Continence issues & urgency (frailty syndromes) Carers Bereavement Case Examples: 1. Lady stopping things slowly, needs support to keep active 2. Man still working, lots of risk factors and wife can benefit from advice too. Considering coming off medications felt not needed anymore – needs review. Potential to attend exercise classes (Abbeycroft Leisure) – change of times to meet people who work. East Suffolk PCN We have selected a cohort of 292 people who are age 35-64, in highly deprived areas, with a history of alcohol use and not prescribed an antidepressant and we think we can improve their access to support services and improve quality of life and reduce their risk of developing serious medical conditions. Thinking Differently Together | 20

Intervention Design Where we are now: • Letters sent to patients (pilot of small cohort local to the intervention – original cohort was 292) • Interventions start mid-April • Dedicated Social Prescriber • 10-week programme for those who opt in • Progress / Evaluation tracker will be in place (accessed at weeks 0, 5 and 10) • Using the Warwick–Edinburgh Mental Well-being Scale (WEMWBS) / PHQ-9 / GAD7 What we have learned Community assets / resources need to be in place prior to implementing interventions (i.e., social prescribers) A need for a clear understanding of roles and resources needed for each attendee prior to PHM programme Buy-in from clinical staff for the entirety of the project Protected capacity for admin staff to assist with ongoing PCN PHM meetings, minutes and actions A dedicated, senior leader in the system to chair the PCN PHM meetings to drive change from the top The re-ID process needs to be more clearly explained and set out for clinicians and practice managers to follow. The CCG and NECS need to be made aware of what is expected of them 21 | Suffolk and North East Essex Integrated Care System

4c. PHM Projects from Primary Care Networks – A Focus on Depression & Anxiety South Rural PCN We have selected a cohort of 107 people, aged between 40-59 years; are diagnosed with obesity, depression and have between 2-5 GP encounters per year. We think we can increase their physical activity level, signpost them to local groups to improve their mental wellbeing; and evaluate the effect on GP encounters. Our patient story: Patient 1 Female, 47 years old. BMI 30 Other diagnosis: depression, PCOS, endometriosis 14 GP encounters in the last 12 months - Referred to Active Suffolk Patient 2 Male, 54 years old. BMI 30 Other diagnosis: depression, hypothyroidism and myocarditis 12 GP encounters in the last 12 months (14 booked) Referred to Active Suffolk Thinking Differently Together | 22

Creffield Medical Group PCN We have selected a cohort of 129 people who are age 8-16 who have a any MH condition (anxiety, low mood, SMI, etc. but not including ASD and LD) and we think we can help them to build resilience through earlier intervention and support for them and their families, with the hope of preventing some longer-term MH problems for this group. Clacton PCN We have selected a cohort of 264 people who are age 40-49 with diagnosed obesity and depression and we think we can optimise their risk factors for CVD while addressing existing condition management using a full complement of a MDT approach involving GPs, NPs, HCAs, Soc Rx, MH team and Pharmacist, along with voluntary sector and lifestyle services. We can use the learning from this cohort to design future effective interventions for our younger population to prevent cardio-vascular disease. Our cohort selection criteria are: Thoughts on the wider determinants and health inequalities for this cohort: Aspects to consider during intervention design: A. Age 40-49 B. Obesity C. Depression NB. Almost 50% of cohort have raised cholesterol, 20% with hypertension and 15% with Diabetes with only 20% having Q-risk score coded A. Low, medium and high deprivation included B. Public transport (and accessibility to services) A. Knowledge of current services to enable better signposting B. Location of services and community transport links C. Drive a multiagency approach D. Support to attend activities (consider for people with MH problems who lack motivation to attend) E. Health Checks, lifestyle service (weight management, smoking cessation, exercise groups), medication reviews, MH support (access to CBT, talking therapies, etc) F. Local leisure centre input G. Communication with cohort – how (text messaging, call, letters, social media, practice based information, PPG, etc.) 23 | Suffolk and North East Essex Integrated Care System

What we have learned Learned to work closer with other services to optimise patient outcomes Optimise services within our PCN - mental health nurse, social prescriber, pharmacist. Encouraged good positive working relationships with other services Positive for experience for administrative staff to have a clinical focus of their work Focus on past, current and future needs of the patient for all clinical staff, HCA, PN, NP, GP Making a difference now, safeguarding patient from possible future health co-morbidities, CVD, diabetes and mental health and associated problems To be proud of achieving this now and continuing to embrace and influence change during such a challenging time for us all in healthcare due to covid Our Patient Story: 49 year old lady with PHM anxiety and depression and agoraphobia Came for focused health check as part of our PHM study Would not normally attend surgery but came in due to special measures being taken at the surgery due to covid where not many patients in waiting room allowed patient confidence to attend Positive interaction and experience with PN, BMI 45.9, QRisk score 3.1, Qdiabetes 12.1, patient willing to investigate diabetes later with blood tests but not at this health check, already under care of mental health services and well controlled at present, focus at this health check for patient was weight, has lost weight herself before so although other services offered declined at this time, described secondary problem with pain in hip, further appointment with GP as struggling to walk. Following GP appointment, X-ray pelvis referral done, attended by patient as motivated to attend from previous positive experience, degenerative changes Patient positive and motivated to lose weight in case of onward referral to MSK and has self referred to physiotherapy Patients hip problem would have remained undiagnosed if not for focussed heath check, patient also plans to come in to have blood tests for further investigation of diabetes, positive outcome for this patient who due to agoraphobia problem has struggled to engage with services. Thinking Differently Together | 24

Colchester Medical Practice PCN We have considered a cohort of 74 people who are 13-18 year olds with anxiety/phobia in highly deprived areas and we think we can begin to understand what this cohort needs in order to provide better support to them and their families, learning from the experience of others (peer support) and empowering families to support the young person. This will assist in the prevention of future mental health problems by teaching resilience and giving them the tools to help them manage their condition, and alleviate early issues. What we have learned S is a 14 yr. old female with severe anxiety and a long history of suicidal ideation, self-harm and risky behaviours. Behaviours included jumping out of bedroom window in the night and taking herself into dark and risky areas alone. Going missing and running away from home. Cutting herself with pieces of glass found on the floor and desperate thoughts of suicide. S has been under secondary care for her mental health and recently discharged from CAMHS and the crisis team. S was triaged by a nurse practitioner and referred for counselling in the GP practice. S very reluctant to engage due to feeling completely let down by other services. Initial assessment deemed S high risk and referral made to CAMHS. Referral declined due to not meeting threshold. S has attended the GP practice on several occasions in crisis and has been managed with care and respect, wounds and dressings changed. Relationship built between counsellor and patient and has involved processes of continued liaison with school, social care with safeguarding concerns and referrals. Also, communication (where permission gained from S) with parent as this was one of the bigger and wider issues around her behaviours. Parental mental health plays a huge factor in this ongoing issue Family Solutions now in place with the family. Courses and workshops have been identified for parent which shows to S she is not the only one ‘making an effort’. Counselling sessions are continuing, S brings herself every week without fail, she embraces each session and works extremely hard. 25 | Suffolk and North East Essex Integrated Care System

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