Does place-based care matter in a post-COVID digital age?

Thomas Beaney, a GP registrar and academic clinical fellow in primary care at Imperial College, and Jonny Clarke, Henry Wellcome Postdoctoral Fellow and former surgical trainee at Imperial College, discuss whether place-based care matters to primary care in the age of COVID

CREDIT: This is an edited version of an articel that originally apepared on BJGP

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. Here 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. However, 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 areas 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.

PCNs were formed in 2019 to operate on broader geographical footprints and 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 the shielding of vulnerable patients.

In our recent article in BMJ Open we used network-based clustering methods to identify how PCNs could 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 five per cent 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 stretching from only 45% in some areas, to 91% in others.

The emergence of ‘digital first’ primary care providers, like ‘GP at hand’, potentially disrupt the traditional, community-focused notion of primary care, given that 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.

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.

We must preserve the community orientation of primary care.