The Lewisham Frailty (loss of resilience that means people don’t bounce back quickly after a physical or mental illness, an accident or other stressful event) Pilot addressed the priority area of frailty support in healthcare delivery, projecting that our current population of approximately 18,000 people experiencing frailty will grow to 30,000 by 2040 (poppi.org.uk). The pilot, which was delivered within The Lewisham Care Partnership PCN in 2021-2022, aimed to proactively identify frail patients at risk of deterioration, implementing a multidisciplinary response to support them, maintain independence, and reduce emergency use of health services

A Population Health Management (PHM) approach was used, leveraging data from acute, community, and primary care services to develop a dashboard to identify priority patients. The criteria for patient identification included being housebound, aged 65 or over, registered with The Lewisham Care Partnership (TLCP) primary care network, having an Electronic Frailty Index (eFI) classification of moderate or severe, and meeting specific additional criteria related to negative changes in e-FI class, fall-related admissions, or emergency admissions.

Patients were provided with wraparound support, with a personalised care plan developed with a multidisciplinary team, following the completion of a Comprehensive Geriatric Assessment (CGA).

Outcomes include positive feedback from patients and family members, met care needs, reduced side effects through medication review, and appreciation for the time and attention of clinicians during home visits. The multidisciplinary team (MDT) found the experience positive, fostering meaningful interactions, professional relationships, and skills development. The pilot achieved a 76% uptake from patients contacted, with 110 Comprehensive Geriatric Assessments (CGA) completed. A review of patient’s use of health services in the six months before and after the CGA found a reduction in acute/unplanned care (eg 27% reduction in unplanned admissions) with an increase in tailored planned/community care (eg 68% increase in activity with the community continence service, and 34% increase in podiatry appointments).

Quotes from participants highlight the value of the service, with patients expressing gratitude for the thoroughness of health assessments. ‘I found the visit very helpful. I didn’t have any family, so I was glad to have someone to help me and grateful to be able to discuss a lot of different things, like hoping to be able to bath/shower again. I was very happy that the doctor took the time to come and see me; they were very thorough with all the questions about my health’.

Next steps involve using learning from the pilot to develop a Lewisham-wide approach to proactive frailty care.

Benefits of PHM in the project include the proactive identification of patients at risk of frailty deterioration and an understanding of patient use of health services. An evaluation of the pilot has also been completed which considered the impact of the pilot on patients and the wider health system.

If you would like any further information on the frailty pilot or evaluation, please contact emma.nixon4@nhs.net (Clinical and Care Professional Lead for Older Adults (SEL ICS – Lewisham).

The COVID-19 vaccination dashboard is designed to proactively support Lewisham GP practices, Primary Care Networks (PCNs),  and the wider system in enhancing the uptake of COVID-19 vaccination, particularly focusing on those most ‘at risk’ within the eligible cohorts and ensuring equity across different communities.

The approach aims to increase the uptake of COVID and flu vaccinations within Lewisham, especially among vulnerable cohorts within the ‘CORE20PLUS’ + Inclusion Populations which represent the Lewisham 20% most deprived populations. The primary goals are to support the flu and COVID vaccination system objectives, reduce health inequalities, create equity in accessing vaccinations, and inform subsequent year’s campaign strategy incorporating health inequalities data.

The dashboard was developed to identify non-age-based cohorts eligible for vaccination, including clinically extremely vulnerable individuals, those with long-term conditions, mental and behavioural disorders, and specific ethnic categories.

The application of Population Health Management (PHM) involves identifying the unvaccinated within the eligible population, analysing demographics, identifying vaccine uptake within health inclusion groups, recognising gaps in services, and using this information to map vaccination services in areas of poor uptake.

The dashboard utilises data from patients registered at Lewisham GP practices, incorporating geomapping for COVID-19 hot spot identification and a risk stratification scoring model for predicting hospital admission risk due to COVID-19. As a result, vaccination campaigns were initiated, targeted using the knowledge of where to focus efforts for increasing uptake in eligible cohorts during the 2022 and 2023 campaigns.

Challenges include the limited timescale of the campaign and the need to update the dashboard format to reflect current criteria.

Outcomes indicate varying uptakes across different health inclusion groups, with plans to take forward the work and learning for the next campaign season, engaging in June 2024, and redesigning the wireframe for automatic data flow.

Next steps involve including language and religion within the demographics and equalities section in the next release to understand the impact of these factors for targeted outreach, updating the dashboard in June 2024, and refreshing eligible cohorts for the next vaccination campaign.

Benefits of PHM in the project include increasing vaccination uptake, identifying unvaccinated vulnerable individuals, using patient-level data for targeted interventions, and informing communication strategies. Multiple data sources are essential, as vaccinations occur and are recorded by various healthcare sectors.

Project Contact Person: Rachael Smith (rachael.smith@selondonics.nhs.uk).

A recent epidemiological study by UKHSA revealed that 77% of lead poisoning cases were associated with Pica. Pica is a recognised eating disorder characterised by the compulsive consumption of non-food substances devoid of nutritional value, such as sand, chalk, playdough, clothing, faeces, hair, and paper. It is more prevalent in specific population groups, particularly in children with learning difficulties and those on the autism spectrum. Pica may be driven by the pursuit of pleasurable sensations or sensory stimulation associated with the act of eating non-food items. Additionally, nutritional factors like low levels of iron or zinc are believed to be associated with Pica. There is extensive evidence that elevated lead levels can cause permanent neurological damage lasting into adolescence and adulthood. If children with Pica are not routinely having their blood tested for lead, then there is the possibility that significant numbers of children with Pica have undiagnosed lead toxicity. Despite recommendations in literature advocating blood lead level testing for children with Pica, it is not widely implemented in routine practice.

The PHM team was approached by the SEL and Lewisham public health leads to see if we could find newly diagnosed children registered with Pica in the past 24 months to prioritise, and ask their GP to call them in for testing.

A data search was completed and validated, and the NHS numbers passed onto to the patients’ registered GP. The GP should notify the Parent/Guardian of the risk of elevated lead levels and request the test. The aim is that the child/parent presents for a blood test, and the GP acts upon results if required. Cases with a blood lead concentration above 5µg/dL (0.24µmol/L) would be notifiable to UKHSA health protection teams for public health case management, while ≥2μg/dL (≥0.09μmol/L) would be managed in line with public health guidance.

The next steps involve expanding the criteria to include diagnoses over 24 months to increase cohort numbers; and verifying a 1-year-old that showed up as a registered Pica patient (it is not usually diagnosed at this young age) for incorrect coding.

Benefits of PHM in the project include screening of children with a diagnosis of Pica and at greater risk of elevated lead levels in their blood to support better, proactive healthcare.

Project Contact Person: Gary Mayo (gary.mayo@selondonics.nhs.uk).

This initiative aims to address the limited access to mental health support for children and young people (CYP), particularly those below specialist Child and Adolescent Mental Health Services (CAMHS) thresholds. It also aims to provide viable options for onward referral when GPs identify mental health needs in patients. The Mulberry Hub, a GP-led Youth Clinic, collaborates with South London and Maudsley NHS Foundation Trust (SLaM) and METRO Charity to deliver integrated primary care, mental health, and youth work services to young people in North Lewisham Primary Care Network (PCN). Funding has been secured to extend this successful project to a second ‘Hub’ in the south of the borough, emphasising representation of the CYP population in the relevant PCN.

The approach involves gathering data on the number of CYP aged between 13-25, registered in the last two years within each PCN with specific conditions (self-harm, suicide ideation, depression/low mood, anxiety, sleeping difficulties), and the ethnicity of those patients.

The selection of the second location for the Mulberry Hub must be evidence-based, focusing on a PCN with the greatest mental health need and the largest population of young people. Addressing health inequalities is a priority, particularly in increasing access to mental health services for CYP from Black and Asian backgrounds.

The project has shown good access and uptake for these groups, but there is a need to ensure representation of the entire CYP population in the relevant PCN, which the PHM data was able to show, to support planning decision-making.

Contact Person: Sarah Entwistle(sarah.entwistle@nhs.net).

This initiative aimed to address health inequalities within underserved communities, specifically focusing on CORE20PLUS + Inclusion Populations in North Lewisham. The goal was to provide holistic health checks and additional services through the Community Health Hub initiative, aligning with the Primary Care Network’s (PCN) objective of improving outcomes for patients at risk of health inequalities.

The PHM approach involved analysing patient identifiable data to identify those within the eligible age range who had not undergone health checks, and who are most at risk of health inequalities in North Lewisham. The criteria included North Lewisham residents with no recent health checks, belonging to ethnic minority groups, living in areas of deprivation, and falling into CORE20PLUS and Inclusion Health/vulnerable groups. The data was grouped by practice to facilitate targeted outreach efforts.

The North Lewisham PCN implemented a Community Health Hub, a mobile facility offering a comprehensive range of health and well-being services. The initiative provided free health checks, support from NHS and community groups, and featured talks and workshops. Collaboration with Red Ribbon Living Well included Hep C and HIV screening.

The expected outcome was the proactive identification of vulnerable populations at risk of health inequalities. These individuals would be invited to attend community hub events, providing them with the opportunity for health checks and discussions with NHS staff, GPs, and community groups.

The benefits of Population Health Management in the project were centred on improving health and well-being, particularly by proactively reaching out to those at greater risk of ill health and experiencing health inequalities.

Contact Person: Gary Mayo (gary.mayo@selondonics.nhs.uk).

This project aims to enhance the identification of older adults who would benefit most from proactive assessments, such as Comprehensive Geriatric Assessments (CGA). The goal is to prevent deterioration, reduce unplanned admissions, and alleviate strain on acute services by managing older adults safely and effectively within the community.

The focus is on identifying frail older adults who are moderately frail, but possibly on the cusp of deteriorating further into severe frailty, so that we can try to prevent that from happening. It will also provide better care for those we find are more frail than the recorded score. We define these people by activity (encounters), i.e. those:

• Who haven’t had recent primary care, community care, or A&E contact
• Who are moderately frail – defined by the Electronic Frailty Index (EFI) score, further defined by the index of multiple deprivation (IMD)
• Who are from CORE20PLUS populations
• Who are without dementia, palliative care, and carers
• Who require fewer than or more than eight medications and have not requested repeat medications in the last six months.

The team are developing a case-finding tool for those we think we can stop becoming more frail. Those identified will be prioritised for a Comprehensive Geriatric Assessment (CGA) by a community nurse to determine if there are interventions and services that could help maintain the patients and prevent them becoming more frail.

The outlined next steps include: building a dashboard to enable end-users to case-find patients, deliver interventions, and track their impacts based on individual CGA, subsequent encounters, clinical markers, or a combination of these indicators.

Contact Person: Rachael Smith (rachael.smith@selondonics.nhs.uk).

NHS England has awarded £2 million per London ICB to develop initiatives preventing the progression to haemodialysis for end-stage kidney failure. The South East London ICB is collaboratively designing a multi-morbidity model of care with one PCN or neighbourhood per borough. This 18-month initiative aims to enhance skills, education and service organisation, ensuring sustainability and scalability.

The model focuses on coordinating primary, secondary and voluntary care services to provide holistic care for patients with multiple long-term conditions. The goal is to personalise care, leading to improved outcomes, efficient service utilisation, and an enhanced care experience. Additionally, the model addresses early detection and optimisation of kidney disease in high-risk groups to delay or prevent end-stage renal failure.

The project is working with one neighbourhood per borough. The PHM team is collaborating with The Lewisham Care Partnership (TLCP) who represent the Lewisham neighbourhood within the project.

The project addresses increasing multi-morbidity in the population, aiming to meet the holistic needs of individuals with long-term conditions for better outcomes and efficient service use. Kidney disease is under diagnosed, undertreated, and has unequal outcomes (especially among lower socioeconomic groups and ethnic minorities) and it often coexists with multiple long-term conditions, frequently caused by hypertension and/or diabetes.

Anticipated outcomes include medical optimisation and improved service use efficiency, particularly for those in CORE20PLUS groups.

The PHM team have assisted by providing a bespoke database for all patients diagnosed with chronic kidney disease (CKD) listing:

• CORE20PLUS group
• outpatient appointment (number and categorised group – cardiology, diabetes, nephrology, other)
• emergency attendances
• last blood pressure (primary + secondary care)
• last eGFR (primary + secondary care).

There has also been a PHM team representative at the majority of in-person co-development workshops, allowing discussion and contribution to the project during development. There was also a joint PHM and Clinical Effectiveness South East London (CESEL) team presentation to all the neighbourhood groups giving a PHM perspective on multi-morbidity, and how local data insights can contribute to the design of the project.

PHM benefits the project by enabling interventions to target underserved groups and operationalising data tools for borough-wide service scaling.

For further information, please contact Kathryn Griffiths (kathryngriffiths1@nhs.net).

In recent years, there has been a rise in the number of patients awaiting surgery, resulting in extended waiting times for treatment. The reduction of waiting lists is a top priority for both Lewisham and Greenwich NHS Trust (LGT) and the national NHS.

Notably, individuals from more economically deprived areas tend to experience prolonged waiting periods, compared to those from the least deprived areas. This disparity is largely driven by the fact that patients in economically deprived areas often contend with a variety of health conditions that can heighten the risks associated with surgical procedures. Failure to meet specific health benchmarks may render patients ineligible for immediate surgery, necessitating efforts to enhance their health and mitigate the potential complications of their procedure. Consequently, these patients endure extended wait times before undergoing surgery.

Our initiative seeks to proactively identify individuals facing healthcare inequalities early in their healthcare journey. By offering targeted support, we aim to optimise their health prior to surgery, ensuring they are well prepared and fit for the procedure during their pre-operative assessment.

In order to tackle the challenge of prolonged waiting lists and address health disparities, LGT has implemented a PHM approach. The initiative involves using an elective dashboard within HealtheIntent, offering a comprehensive overview of all patients currently on LGT’s elective waiting list.

The criteria for identifying the target patient cohort include parameters such as:

• uncontrolled Hb and/or glycaemia
• patients from the two most deprived quintiles based on Indices of Multiple Deprivation
• individuals with learning disabilities
• patients dealing with Serious Mental Illness (SMI), and
• those over the age of 65 exhibiting moderate/severe frailty, or having had two attendances at the Emergency Department, and living alone.

A diverse clinical panel reviewed identified patients. The panel included a consultant geriatrician, anaesthetist, surgeon, allied health professionals and a general practitioner. After the review, patients could be referred to pathways like anaemia optimisation, diabetes management, frailty and or complex medical needs support, smoking cessation and weight management.

While it’s early to determine concrete outcomes, initial insights from patient reviews show promising results. Key findings include a diverse patient background, with 50% from ethnic minority backgrounds, 34% requiring anaemia optimisation, 30% referred for frailty support, and 23% proceeding through usual pathways.

The project’s current focus is on Trauma and Orthopaedics patients, with plans to expand in 2024 to include Ear, Nose, and Throat, and General surgery patients. Evaluation will assess the impact of a holistic approach on various factors, including:

• improved clinical outcomes
• reduced patients not-fit for surgery
• minimised short notice surgery cancellations
• enhanced patient experience
• decreased inappropriate referrals
• reduced monitoring time, and
• reduced healthcare contacts.

Access to comprehensive clinical information through HealtheIntent has been crucial for identifying appropriate patients. The system helps assess recent test results, identifying potential surgery risks. It also helps identify patients with learning disabilities or serious mental illnesses, allowing for a more targeted approach.

For further information, please contact Matt Hopkins (matthew.hopkins4@nhs.net).

Hypertension, a condition linked with significant co-morbidity, is notably prevalent within CORE20PLUS groups. While resources are consistently invested in optimising care for those with existing hypertension, the coordination of population-level disease prevention remains less common.

The utilisation of the HealtheIntent ready-made predictive data tool aims to identify individuals in Lewisham and Greenwich at medium, high and very high risk of developing hypertension within the next five years.

The tool will enable the implementation of targeted interventions, including lifestyle advice, dietary guidance, weight loss programs, and smoking cessation efforts, tailored to individuals based on their identified risk level.

Targeting resources to reduce cardiovascular disease and addressing risk factors for those at the highest risk of developing hypertension is expected to yield improved outcomes for the overall population.

The model will be based on analyses of factors which contribute to an increased chance of developing hypertension. These factors will be modelled on data from the Lewisham and Greenwich population.

The development and use of the tool are under discussion within a collaborative group comprising data scientists, clinicians, population health experts and borough-based commissioners of care.

A potential challenge lies in ensuring the coordinated implementation of interventions based on the tool’s outcomes.  The PHM team is driving data-led preventative work by creating capacity in the form of new ways of working with both community and allied health professionals to target cardiovascular risk factors. The work looks to explain and engage with patients, to help them understand their risk factors and the tools available to them to reduce risk.

Being able to quantify risk in a meaningful and population-tailored way means that targeted prevention work can be engaged across a high-risk borough in a way that has not happened before.

For further information, please contact Rachael Smith (rachael.smith@selondonics.nhs.uk) and Kathryn Griffiths (kathryngriffiths1@nhs.net).