What is the positive change that has emerged through new collaborations or partnerships during Covid-19 that your project is going to embed?

COVID-19 impacted on the wellbeing of adults (18-65), who exhibited “syndromes” of distress such as low mood and unexplained symptoms such as acute pain. Identification of this group of patients and taking a holistic, biopsychosocial and de-medicalised approach to care is paramount; these patients often come to harm from over-investigation and prescriptions of addictive medications such as opiates.

During the pandemic, the functional illness team at Pathfields Medical Group (primary care network) integrated with mental health teams, social prescribers, and physiotherapists to see if a joined up wellbeing focus may go further for this patient group.

The first stage of employing a population health management approach to this patient group was developing a systematic approach to idenfication.  Once identified, it is hoped that they can be proactively case managed and offered a menu of options, that aim to build wellbeing and resilience in the patient and their support network.

What does your project aim to achieve?

It has long been recognised that some adults 18-65 have a disproportionately high use of primary care and do not, strictly speaking, have a medical problem. Ultimately, they are consulting their GP due to profound distress as they live a life that is biopsychosocially extremely complicated. We summarise this as “adults with complex lives.”

The aim of the project is to develop a casefinding tool that systematically and opportunistically identifies adults aged 18-65 with complex lives and would benefit from proactive multidisciplinary case management using a demedicalised approach, that aims to build resilience, empower, and promote wellbeing.

To develop this casefinding tool, it is necessary to achieve the following:

1. Identify and validate “syndromes” of complex lives that may present to primary care.

2. Validate the above syndromes. In this case it would be whether a clinician feels that the patient lives a complex life and would benefit from proactive, multidisciplinary casemanagement.

How will the project be delivered?

Firstly a search of patients aged 18-65 with 6+ GP appointments in a year or 3+ A&E attendances in a year long period would be created in a practice population. The records will be reviewed to exclude medical causes for primary care/A+E useages if appropriate.

The refined search would be analysed to ascertain which one/combination of the features below were most associated with being on the above list:

1. Sick note >6 months

2. On long term addictive medications e.g. opiates

3. Children on a child protection plan

4. History of domestic violence

5. Adult safeguarding

6. Personality disorder

7. Functional illness

If there was still a significant gap, the remaining patient records of patients who were not in the 7 groups above would be analysed to see if further groups were needed.

The list would then be validated by asking the GP who knew the patient best to confirm whether they were adults with complex lives.

How is your project going to share learning?

Learning will be disseminated using the Q community, AHSNs, webinars, presentations at local, regional and national level, and publications in medical journals