Does place-based care matter to primary care in the post-COVID-19 digital age?

Thomas Beaney is a GP registrar and academic clinical fellow in primary care at Imperial College interested in the interface between primary care, public health and health policy. He is on Twitter: @DrThomasBeaney

Jonny Clarke is a Sir Henry Wellcome Postdoctoral Fellow and former surgical trainee at Imperial College, whose work focusses on understanding the complex dynamics between patients and organisations within the healthcare system. He is on Twitter: @Jonny_M_Clarke

For GPs to engage effectively and proactively in population health we need to understand not only who the population is, but also where they live. In this blog, we discuss our recent work exploring how upscaling GPs into Primary Care Networks (PCNs) can facilitate the provision of local place-based population healthcare.

General practice is well-positioned to identify and intervene in the wider determinants of health.° Many of the ingredients are already in place: registered patient lists, extensive data, and the ability to engage both proactively and opportunistically with patients. But in contrast to public health bodies, primary care’s responsibilities lie with their registered patients, rather than a geographical area. How easy is it to engage in public health activities without an understanding of the local area across which GPs operate? Engagement with the wider determinants of health, such as housing, fast-food and air pollution, relies upon understanding local needs and idiosyncrasies, and requires a defined area of responsibility.

With the formation of PCNs in 2019 operating on broader geographical footprints, there is an expectation they will become key players in population health° management and in anchoring community providers.° The collaborations enabled by their formation have already shown benefits during the COVID-19 response,° with PCNs adapting dynamically to the local needs of their communities with respect to prescribing, testing and shielding of vulnerable patients.

In our recent article in BMJ Open° we used network-based clustering methods to identify how PCNs would best maximise the representation of their populations and understand their geographies, in order to better support the provision of population healthcare through primary care.

We found extensive overlap of the boundaries in which the population registered at each GP lives. This was particularly the case in urban areas with a high density of practices, and a relatively mobile patient population. Our study found that on average in London, within each small geographical unit, (Lower Layer Super Output Area, consisting of around 1,500 people) an average of five different GP practices provide primary care, with 5% receiving care from ten or more practices, which may hamper the ability of primary care to contribute meaningfully and efficiently to population health.

We found that by grouping GPs into larger communities in the form of PCNs using a purely data-driven approach, the local population coverage was much improved compared to that achieved by individual practices alone. Within the geography assigned to each PCN, on average 70% of the population were registered to a practice within the PCN, albeit with a wide range from only 45% in some areas to 91% in others. The interactive map displays how these PCNs in London emerged, along with the assigned geographies, which are exclusive to each.

The emergence of ‘digital first’ primary care providers, like ‘GP at hand’, potentially disrupt the traditional community-focused notion of primary care, given patients can be registered and consult with a GP many miles from the physical location of the surgery. The move towards remote primary care has been further boosted during the COVID-19 pandemic, with a significant increase in the proportion of telephone appointments and a push towards a ‘total triage’ model.° While this may benefit some patients, particularly those who are younger and with fewer co-morbidities, a decline in place-based care may impair the ability of GPs to understand and intervene in population health locally.

PCNs are still in the process of defining their roles and responsibilities, but over the course of a few months, many have been thrust into the centre of the primary care response to the COVID-19 pandemic. For their role in population health to be fully realised, an understanding is needed of both ‘who’ this population refers to, and ‘where’ this population resides, and our tool may aid in this purpose. Place-based delivery of care is under threat, but the case for GP involvement in the health of their local communities has never been stronger and we must preserve the community orientation of primary care.

 

Featured photo by Denise Chan on Unsplash