Benfleet Primary Care Network (PCN), led by Dr Rizwan Khan and his practice, has embarked on a transformative approach to healthcare. Employing a Population Health Management (PHM) framework, Benfleet PCN has shifted from treating medical conditions in isolation to a more holistic model that considers various factors affecting the well-being of their residents.
The PCN initiated an in-depth analysis of 48,000 local residents. They focused on a group of 63 residents aged between 60 and 74, who were grappling with multiple complex health issues like obesity, depression, hypertension, and diabetes. Dr Khan underscored the importance of intervening in the lives of these individuals to stave off more severe conditions in the future.
Not limiting themselves to clinical concerns, the Benfleet team took a broader perspective. Health Coach Jo, from the Castle Point Association of Voluntary Services, engaged in conversations to understand each individual’s unique circumstances. This involved discussing personal goals, financial constraints, and social support networks. By doing so, the team was able to direct residents towards relevant support, such as weight loss classes and therapy.
The case of a retired driver who felt his life had lost its purpose exemplifies the power of this new approach. After engaging in a detailed conversation with the health coach, this individual was put on a tailored care plan. Immediate changes followed. He began walking and took steps to re-engage with his hobby of pigeon racing.
Subsequent reviews have shown that the gentleman has lost weight and adjusted his diabetes management, all while feeling more supported. The transformation underscores Dr Khan’s sentiment that the programme has given the Benfleet team “a new way of approaching the health and wellbeing of our residents.”
Collaboration is key. Benfleet PCN has formed partnerships with local voluntary organisations, increasing their impact and reach. The team is entirely committed to this holistic model, which empowers the individual to take control of their health and wellbeing.
Through its innovative application of Population Health Management, Benfleet PCN demonstrates that healthcare can go beyond clinical interventions to truly support the well-being of community members. This community-centric, holistic approach represents a radical shift in healthcare delivery and offers a promising model for improving population health across broader domains.
Benfleet PCNJ PHM Programme
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In Benfleet we are
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seeing demand for services increase year
after year, with more and more patients
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presenting with complex medical
and emotional challenges.
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We were keen to explore new ways of working, using data
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to help predict future health needs and intervene earlier.
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Gaining a deeper understanding
on the needs of the individual
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rather than a doctor simply prescribing a medical solution.
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Just to give you a background, I’ve been
working in NHS for over 12 years
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now and the biggest difference,
what I feel is we always firefight.
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Imagine you have a road
which is prone for accidents.
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You have two options.
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Either you can build a hospital next to it because you know
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there will be more patients or fix the problem.
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So in NHS, I believe we are trying to build those hospitals,
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creating more jobs and roles, but we are
not thinking about fixing the road.
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Why the accident is taking place? Invest in what measures needs to be put.
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Working in community, I strongly believe
if a patient goes into hospital
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for an unplanned admission, that means
we failed them in the community.
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If we don’t do something today, same thing
will happen in next 5 to 10 years.
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So proactive approaches identify those
patients who is going to benefit.
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We want every service, whether it’s health,
social service, voluntary sector.
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All the other services who provide service to
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our patients are aligned together and work together.
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GP practices in Benfleet have been working with other partners
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to identify and support residents at
greatest risk of poor health outcomes.
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A personalised approach has resulted
in a clearer picture of factors
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that can impact on their health and wellbeing.
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So as a health and wellbeing coach,
I make contact with patients first of all
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and I discuss with them what they
would like to achieve in the future.
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One of the people I have helped, his main goal
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was to be able to exercise more and
to actually leave his family home.
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He was struggling with his health
with lower back pain that no one
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at the present time seems to be able
to get to the bottom with.
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He was feeling really low.
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He was feeling tired.
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He had to give up work in 2020 due to COVID 19,
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and he struggled with that process
of not being able to work anymore.
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After just a short amount of time
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he has lost weight, adjusted his diabetes medication
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and decided that he wants to start
racing pigeons again as a hobby.
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His wife has already ordered his pigeons, and most importantly,
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he’s feeling positive about the future.