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Population Health Management

Selby Town Primary Care Network (PCN), which is made up of four GP practices serving an urban population of more than 50,000 patients, has been taking part in a 20-week Population Health Management project through national programme provider Optum UK.

It meant local NHS staff working with partners across the Selby district such as Humber, Coast and Vale Health and Care Partnership, Selby District Council, North Yorkshire County Council's Public Health and Stronger Communities teams and Community Services and York and Scarborough Teaching Hospitals NHS Foundation Trust – as well as the third sector through the Two Ridings Community Foundation – to develop support for patients aged 50-64 with moderate hypertension and frailty, based on their needs.

The diversity of partners involved meant the focus could be on finding wide-ranging solutions to support people's health and wellbeing, rather than purely medical interventions.


What you told us about your health and services

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We asked patients aged between 50-64 in Selby Town PCN about the issues that most affect them, including medication and digital access. Our patients told us that that they weren't able to access online services, felt anxious because of COVID-19 and were struggling with a lack of motivation.

Their feedback showed that they wanted more exercise and activity serssions, such as swimming and yoga, and more groups to help and motivate them. Gathering this feedback has meant that we can start to develop new services with our patients, for our patients.

Click the links below to find out more about the work that enables successful Population Health Management in Selby Town PCN.


Martin's story

Martin is a local patient who is taking part in the ongoing process to develop better support for patients aged between 50-64 with moderate hypertension and frailty. He took redundancy from his role as an operations manager in the engineering industry during the COVID-19 pandemic, and planned to use his early retirement to get on top of his health. However, it was being contacted by the PCN team to take part in the Population Health Management project that provided the "nudge" he needed to get moving.

He said: "My job was very stressful with long hours, and I didn't have a lot of time to look after myself. After I took redundancy my son was telling me I needed to do something, and I took that letter as inspiration to say 'I'm going down this route, I'm going to talk to these people and see what they can offer and how they can help me'.

"I had the first telephone call with one of the team and it was really, really good. I think we must have been on the telephone for two hours. It was a really good conversation – she went through all of my issues. It really inspired me to know there was something I could get involved with. Since having that telephone conversation I've been coming to the meetings and trying to improve my health."

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The former super-fit military man Martin, who hopes losing weight will mean he can have an operation on a tear in his knee, also has sleep apnoea – but he is already reaping the benefits of his new approach, exercising in the swimming pool at Selby Leisure Centre most days in tandem with dietary changes – including fish for breakfast to ensure the pounds are dropping off.

"I'm in the lucky position where I can afford to do it and I've got time to do it. I've taken control and I'm enjoying life – I've got two great sons, my wife, two great daughters in law, a granddaughter and hopefully more grandchildren to come."

Click here to read Martin's full story.


Additional roles

The initial questionnaire for patients was put together with contributions from all partners, and Selby Town PCN Care Coordinators and Wellbeing Link Workers led on contacting patients and going through the questionnaire with them over the phone as well as the ongoing focus groups.

Dr Nick Jackson, Selby Town PCN Clinical Director; Fiona Bell-Morritt, Lead Officer at NHS Vale of York CCG; Helen Brazil, Dementia Care Coordinator; and Alice Houlden, Frailty Care Coordinator discuss the overwhelmingly positive impact the care coordinators are making on the wider team and in particular on the vulnerable members of their patient community.

From the beginning of their journey, and the adoption of a population health management strategy, to recruitment and development of the care coordination team, an overview of the role itself and the work that’s encompassed, the benefits on offer to both the internal teams and externally, and the lessons learned. This Ockham Health podcast episode is a testament to the powerful influence that the new roles can have on improving patient outcomes and supporting GPs during a time when demand for primary care services has never been higher.

Listen to the podcast below.

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