Slough medical centre optimises patient outcomes with digital approach

Kumar Medical Centre in Slough is using a population health management approach to revolutionise its annual NHS Quality and Outcomes Framework (QOF) to help free up time for more appointments and optimise patient outcomes.

By organising its QOF reviews using a segmented approach, the Kumar Medical Centre is freeing up valuable clinical time for the busy winter period, as well as improving patient outcomes for its more complex patients.

Using the Patient Need Groups (PNGs) segmentation tool in the Johns Hopkins Adjusted Clinical Groups (ACG) System, the healthcare team were able to identify its most complex patients early in the year and carry out planned QOF appointments before seasonal pressures began and when resources were more flexible.

At the NHS Confederation Expo 2023, held in June this year, a panel of clinicians and change management experts told the audience that population health management has the potential to eliminate some of the legwork in health visits.

The ACG System is an international method for predictive population analysis. PNGs categorise patients into 11 mutually exclusive segments based on their overall level of complexity once taking into account all of their diagnoses.

The Kumar Medical Centre team was able to segment patients in the Slough region who needed a QOF review, based on which PNG they were in, and use this metric to decide when to see the patient, the type of healthcare professional who could assess their overall need, and whether the patient could be reviewed using digital technology, or required a face to face appointment.

Dr Kumar said: ‘By using a population health management approach and a single metric we seem to have solved the perennial problem of not having enough appointments in the winter months.

“By identifying our most complex patients using the Johns Hopkins PNGs early in the financial year, we can optimise their health before autumn and winter and reduce the risk of emergency admissions.

“Essentially, we review patients according to complexity rather than their date of birth, meaning we can allocate the right healthcare professional to the right patient at the right time while making the most efficient use of our personnel.

“Using PNGs, we have organised our resources to work much more efficiently – the principal is fundamentally simple – but really effective.’”

Using the population health management tool, the Slough centre has been able to review all of its most complex patients and complete 70% of QOF reviews by September 2023 – in comparison to just 33% the year before.

This has allowed them to more effectively use clinical time, reduce the need for repeated appointments and create vital GP and clinical capacity within the system.