Understanding patient's use of primary care services to inform service redesign for management of chronic disease, specifically in the context of multimorbidity

The operating context for primary care within the UK NHS is facing change as a consequence of the NHS Health & Social Care Act [2012]. As providers of primary care in England, general practices will be operating as contractors... [ view full abstract ]

The operating context for primary care within the UK NHS is facing change as a consequence of the NHS Health & Social Care Act [2012]. As providers of primary care in England, general practices will be operating as contractors in an independently regulated, market-driven healthcare economy. This significant change requires optimal use of clinical and business information systems within practices to underpin person-centric delivery of services.

A major challenge in the delivery of primary care is meeting the needs of an increasing practice population that is older and living with multimorbidities. The problem in service provision for these patients is that payment for patient care has traditionally, in England, been linked to a particular disease group and its associated targets rather than being centred on the patient. Thus patients attend multiple appointments with GP and practice nurses for review, diagnostics and management. This accounts for approximately 40% of activity in primary health care services which is captured in a GP practices clinical information systems. This includes data relating to consultations, appointments, reviews, referrals, prescription authorisation, phone calls and letters for these patients.

Aim: The project reported here aimed to develop a generic, person-centred system for efficient management of chronic disease in General Practice that is informed by data mining of clinical information systems.

Method and findings: The initial step in this process has been the development of a datawarehouse that allows for interrogation and interpretation of practice data. Using meta-data mining tools patient usage of the service has been mapped and processes to identify likely trends in future service usage are in development. The presentation of these initial findings will be given in addition to a description of how these findings are being considered for redesign of services for management of multimorbidity in the context of chronic disease.