Background
The South Somerset Symphony Programme – Enhanced Primary Care
What is Enhanced Primary Care? | A new model of primary care that aims to upskill the workforce by adding a new non-medical role to the primary care team: health coaches |
Target group of Enhanced Primary Care | Patients with at least one chronic condition (~ 18% of the population in South Somerset) |
Role of the health coach | To act as a single point of contact for patients; and to provide additional self-management and education support for patients |
Background of the health coach | Typically from an administration/receptionist background, but some practices have also hired former social workers |
Training of the health coach | All health coaches receive a two-day training course in health coaching. Health coaches are trained in different techniques to improve person-centeredness by supporting patients in identifying and achieving their goals |
Number of GP practices that have implemented Enhanced Primary Care | 17 out of 19 practices in South Somerset, with some at a more advanced stage than others. The scheme has been rolled out in three waves across the region |
Methods
Data
Intervention timing and controls
Outcomes | GPPS Measure | Description | Variable |
---|---|---|---|
Health status
| |||
EQ-5D-5L | Mobility | Ability to walk | Continuous |
Self-care | Ability to dress and wash oneself | ||
Usual activities | Performance in “work, study, housework, family or leisure activities” | ||
Pain/discomfort | Level of pain and discomfort | ||
Anxiety/depression | Level of anxiety and/or depression | ||
Physical functioning | Mobility | 1 (lowest), 5 (highest) health status | |
Usual activities | |||
Pain/discomfort | |||
Psychological wellbeing | Anxiety/depression | 1 (lowest), 5 (highest) health status | |
Resilience | Self-care | 1 (lowest), 5 (highest) health status | |
Confidence | Confidence in managing own health | ||
Experience of care
| |||
Person-centeredness | GP rating | Rating of GP quality based on last appointment | 1 (lowest), 5 (highest) quality |
Continuity of care | Seeing preferred GP | Frequency of seeing preferred GP | 1 (never or almost never), 2 (some of the time), 3 (a lot of the time), 4 (always or almost always) |
Health behaviour
| |||
Smoking habit | Smoking habit | 1 (never smoked), 2 (former smoker), 3 (occasional smoker), 4 (regular smoker) | |
Health care utilisation
| |||
Primary care utilisation | GP visit | Time since last GP appointment | 1 (more than 12 months ago), 2 (between 6 and 12 months), 3 (between 3 and 6 months), 4 (in the past 3 months) |
Nurse visit | Time since last nurse appointment | 1 (more than 12 months ago), 2 (between 6 and 12 months), 3 (between 3 and 6 months), 4 (in the past 3 months) |
Estimation strategy
Enhanced Primary Care Patients | % | Control Patients | % | ||||
---|---|---|---|---|---|---|---|
Patients with two chronic conditions
|
100
|
Patients with two chronic conditions
|
100
| ||||
Arthritis or long-term joint problem | High blood pressure | 10.1 | Arthritis or long-term joint problem | High blood pressure | 10.7 | ||
Another long-term condition | High blood pressure | 8.7 | Diabetes | High blood pressure | 9.6 | ||
Diabetes | High blood pressure | 8.0 | Another long-term condition | High blood pressure | 7.3 | ||
Arthritis or long-term joint problem | Long-term back problem | 5.0 | Arthritis or long-term joint problem | Long-term back problem | 5.8 | ||
Angina or long-term heart problem | High blood pressure | 4.0 | Asthma or long-term chest problem | High blood pressure | 4.4 | ||
Patients with three chronic conditions
|
100
|
Patients with three chronic conditions
|
100
| ||||
Arthritis or long-term joint problem | High blood pressure | Long-term back problem | 6.9 | Arthritis or long-term joint problem | High blood pressure | Long-term back problem | 7.4 |
Arthritis or long-term joint problem | High blood pressure | Diabetes | 4.3 | Arthritis or long-term joint problem | High blood pressure | Diabetes | 5.0 |
Arthritis or long-term joint problem | High blood pressure | Another long-term condition | 4.1 | Arthritis or long-term joint problem | High blood pressure | Another long-term condition | 3.5 |
Arthritis or long-term joint problem | High blood pressure | Angina or long-term heart problem | 3.2 | Arthritis or long-term joint problem | High blood pressure | Asthma or long-term chest problem | 3.5 |
Arthritis or long-term joint problem | High blood pressure | Asthma or long-term chest problem | 4.1 | Arthritis or long-term joint problem | High blood pressure | Angina or long-term heart problem | 3.2 |
Robustness checks
Results
Sample characteristics
Variable | Enhanced Primary Care | Controls | SMD | ||||
---|---|---|---|---|---|---|---|
N | Meana | SD | N | Meana | SD | ||
Outcomes
| |||||||
EQ-5D-5L score | 1,143 | 0.6671 | 0.2511 | 601,527 | 0.6191 | 0.2803 | 0.1713 |
Physical functioning | 1,195 | 0.6954 | 0.2382 | 634,358 | 0.6611 | 0.2493 | 0.1377 |
Psychological wellbeing | 1,190 | 0.8445 | 0.2131 | 637,174 | 0.8011 | 0.2516 | 0.1725 |
Resilience | 1,207 | 0.8335 | 0.1812 | 641,951 | 0.8051 | 0.1994 | 0.1422 |
Person-centeredness | 1,102 | 0.8829 | 0.1550 | 591,869 | 0.8580 | 0.1794 | 0.1390 |
Continuity of care | 952 | 0.7598 | 0.3041 | 439,459 | 0.7228 | 0.3113 | 0.1187 |
Smoking habit | 1,220 | 0.2369 | 0.2647 | 655,448 | 0.2624 | 0.3004 | −0.0849 |
Primary care utilisation | 1,238 | 0.8538 | 0.1842 | 662,676 | 0.8461 | 0.1888 | 0.0407 |
Individual characteristics
| |||||||
Male | 1,250 | 0.4448 | 0.4971 | 673,788 | 0.4474 | 0.4972 | −0.0052 |
White | 1,250 | 0.9712 | 0.1673 | 673,788 | 0.8852 | 0.3188 | 0.2699 |
Full-time paid work | 1,250 | 0.1280 | 0.3342 | 673,788 | 0.1308 | 0.3372 | −0.0083 |
Fully retired from work | 1,250 | 0.5880 | 0.4924 | 673,788 | 0.5334 | 0.4989 | 0.1095 |
Age under 35 | 1,250 | 0.0200 | 0.1401 | 673,788 | 0.0241 | 0.1532 | −0.0265 |
Age 65 and over | 1,250 | 0.6952 | 0.4605 | 673,788 | 0.6253 | 0.4840 | 0.1444 |
Last contacted GP < 6 months ago | 1,250 | 0.8720 | 0.3342 | 673,788 | 0.8720 | 0.3341 | −0.0001 |
Last contacted GP > 6 months ago | 1,250 | 0.1248 | 0.3306 | 673,788 | 0.1212 | 0.3264 | 0.0109 |
Testing for parallel trends
Difference-in-differences analysis results
Primary Analysis | ||||||||||
---|---|---|---|---|---|---|---|---|---|---|
Outcomes | Unadjusted means | Unadjusted difference-in-differences | N | Adjusteda difference-in-differences (95% CI) | ||||||
Treatment Pre/Post | Control Pre/Post | Simplified | Wave 1 | Wave 2 | ||||||
Health status
| ||||||||||
EQ-5D-5L | 0.6671 | 0.6702 | 0.6431 | 0.6410 | 0.0052 | −0.0226 | 0.0199‡‡ | 874,075 | −0.0263 | (−0.0679 to 0.0152) |
Physical functioning | 0.6954 | 0.7147 | 0.6778 | 0.6809 | 0.0161 | −0.0098 | 0.0203‡‡ | 919,785 | −0.0048 | (−0.0424 to 0.0328) |
Psychological wellbeing | 0.8445 | 0.8226 | 0.8225 | 0.8148 | −0.0142 | −0.0408 | 0.0187‡ | 924,974 | −0.0174 | (−0.0283 to -0.0065)‡‡ |
Resilience | 0.8335 | 0.8396 | 0.8207 | 0.8178 | 0.0091 | −0.0008 | 0.0147‡‡ | 931,207 | −0.0132 | (−0.0758 to 0.0493) |
Experience of care
| ||||||||||
Person-centeredness | 0.8829 | 0.8738 | 0.8662 | 0.8650 | -0.0080 | −0.0149‡‡ | −0.0140‡‡ | 854,635 | −0.0356 | (−0.0530 to -0.0183)‡‡ |
Continuity of care | 0.7598 | 0.7176 | 0.7410 | 0.7091 | -0.0103 | −0.0112‡‡ | −0.0218‡‡ | 622,963 | −0.0749 | (−0.2011 to 0.0513) |
Health behaviour
| ||||||||||
Smoking habit | 0.2369 | 0.2188 | 0.2446 | 0.2386 | -0.0120 | −0.0089 | −0.0126 | 952,453 | −0.0077 | (−0.0273 to 0.0120) |
Health care utilisation
| ||||||||||
Primary care utilisationb | 0.8538 | 0.8534 | 0.8470 | 0.8428 | 0.0038 | 0.0041 | −0.0063‡‡ | 959,800 | −0.0368 | (−0.1022 to 0.0285) |
Robustness check 1 | Robustness check 2 | Robustness check 3 | |||||||
---|---|---|---|---|---|---|---|---|---|
(Alternative control group) | (Medium-term effects) | (Simplified analysis) | |||||||
Outcomes | N | Adjusteda difference-in-differences (95% CI) | N | Adjusteda difference-in-differences (95% CI) | N | Adjusteda difference-in-differences (95% CI) | |||
Health status
| |||||||||
EQ-5D-5L | 81,924 | −0.0266 | (−0.0702 to 0.0171) | 874,075 | −0.0104 | (−0.0550 to 0.0340) | 874,075 | 0.0014 | (−0.0158 to 0.0186) |
Physical functioning | 85,457 | −0.0084 | (−0.0460 to 0.0292) | 919,785 | 0.0078 | (−0.0425 to 0.0582) | 919,785 | 0.0096 | (−0.0076 to 0.0268) |
Psychological wellbeing | 85,923 | −0.0150 | (−0.0150 to 0.1124) | 924,974 | −0.0514 | (−0.0705 to -0.0324)‡‡ | 924,974 | −0.0090 | (−0.0301 to 0.0121) |
Resilience | 86,295 | −0.0166 | (−0.0803 to 0.0470) | 931,207 | 0.0161 | (−0.0168 to 0.0489) | 931,207 | 0.0062 | (−0.0090 to 0.0214) |
Experience of care
| |||||||||
Person-centeredness | 78,939 | −0.0331 | (−0.0566 to -0.0100)‡‡ | 854,635 | −0.0212 | (−0.0534 to 0.0110) | 854,635 | −0.0068 | (−0.0218 to 0.0082) |
Continuity of care | 62,872 | −0.0742 | (−0.2108 to 0.0624) | 622,963 | −0.0340 | (−0.1042 to 0.0361) | 622,963 | −0.0141 | (−0.0530 to 0.0248) |
Health behaviour
| |||||||||
Smoking habit | 87,912 | −0.0022 | (−0.0349 to 0.0304) | 952,453 | 0.0220 | (−0.0204 to 0.0644) | 952,453 | −0.0160 | (−0.0344 to 0.0023) |
Health care utilisation
| |||||||||
Primary care utilisationb | 88,595 | −0.0402 | (−0.1028 to 0.0223) | 959,800 | 0.0025 | (−0.0244 to 0.0294) | 959,800 | 0.0064 | (−0.0070 to 0.0197) |
Primary Analysis | ||||||||||
---|---|---|---|---|---|---|---|---|---|---|
Outcomes | Unadjusted means | Unadjusted difference-in-differences | N | Adjusteda difference-in-differences (95% CI) | ||||||
Treatment Pre/Post | Control Pre/Post | Simplified | Wave 1 | Wave 2 | ||||||
Health status
| ||||||||||
EQ-5D-5L | 0.8192 | 0.8139 | 0.8060 | 0.8036 | −0.0030 | −0.0054 | 0.0054‡‡ | 3,147,503 | 0.0004 | (−0.0103 to 0.0111) |
Physical functioning | 0.8557 | 0.8571 | 0.8438 | 0.8455 | −0.0004 | −0.0029 | 0.0048‡‡ | 3,242,123 | 0.0044 | (−0.0116 to 0.0204) |
Psychological wellbeing | 0.9013 | 0.8892 | 0.8888 | 0.8824 | −0.0056 | −0.0143 | 0.0073‡‡ | 3,267,482 | −0.0034 | (−0.0078 to 0.0011) |
Resilience | 0.8927 | 0.8929 | 0.8829 | 0.8817 | 0.0015 | 0.0022 | 0.0046‡‡ | 3,238,682 | 0.0038 | (−0.0139 to 0.0214) |
Experience of care
| ||||||||||
Person-centeredness | 0.8759 | 0.8723 | 0.8503 | 0.8523 | −0.0056 | −0.0055‡‡ | 0.0010‡‡ | 2,919,957 | −0.0155 | (−0.0494 to 0.0184) |
Continuity of care | 0.7465 | 0.7083 | 0.7037 | 0.6787 | −0.0132 | −0.0173‡‡ | −0.0187‡‡ | 1,774,615 | −0.0794 | (−0.2058 to 0.0470) |
Health behaviour
| ||||||||||
Smoking habit | 0.2113 | 0.2034 | 0.2204 | 0.2128 | −0.0002 | 0.0030 | 0.0046‡‡ | 3,368,788 | 0.0088 | (0.0009 to 0.0167)‡ |
Health care utilisation
| ||||||||||
Primary care utilisationb | 0.7347 | 0.7299 | 0.7366 | 0.7294 | 0.0023 | −0.0165‡ | 0.0091 | 3,384,804 | −0.0331 | (−0.0448 to -0.0214)‡‡ |
Robustness Check 1 | Robustness Check 2 | Robustness Check 3 | |||||||
---|---|---|---|---|---|---|---|---|---|
(Alternative Control Group) | (Medium-Term Effects) | (Simplified Analysis) | |||||||
Outcomes | N | Adjusteda difference-in-differences (95% CI) | N | Adjusteda difference-in-differences (95% CI) | N | Adjusteda difference-in-differences (95% CI) | |||
Health status
| |||||||||
EQ-5D-5L | 294,272 | 0.0014 | (−0.0125 to 0.0153) | 3,147,503 | −0.0019 | (−0.0156 to 0.0118) | 3,147,503 | −0.0023 | (−0.0104 to 0.0059) |
Physical functioning | 301,710 | 0.0049 | (−0.0126 to 0.0224) | 3,242,123 | 0.0050 | (−0.0129 to 0.0230) | 3,242,123 | −0.0003 | (−0.0083 to 0.0076) |
Psychological wellbeing | 303,519 | −0.0020 | (−0.0107 to 0.0066) | 3,267,482 | −0.0211 | (−0.0351 to -0.0071)‡‡ | 3,267,482 | −0.0036 | (−0.0110 to 0.0038) |
Resilience | 301,024 | 0.0035 | (−0.0151 to 0.0220) | 3,238,682 | 0.0033 | (−0.0096 to 0.0163) | 3,238,682 | 0.0007 | (−0.0040 to 0.0055) |
Experience of care
| |||||||||
Person-centeredness | 268,370 | −0.0143 | (−0.0515 to 0.0230) | 2,919,957 | −0.0169 | (−0.0566 to 0.0228) | 2,919,957 | −0.0065 | (−0.0192 to 0.0061) |
Continuity of care | 178,630 | −0.0774 | (−0.2051 to 0.0503) | 1,774,615 | −0.0594 | (−0.1141 to -0.0047)‡ | 1,774,615 | −0.0128 | (−0.0410 to 0.0154) |
Health behaviour
| |||||||||
Smoking habit | 311,270 | 0.0113 | (−0.0017 to 0.0244) | 3,368,788 | 0.0000 | (−0.0410 to 0.0409) | 3,368,788 | −0.0011 | (−0.0152 to 0.0131) |
Health care utilisation
| |||||||||
Primary care utilisationb | 312,654 | −0.0372 | (−0.0565 to -0.0178)‡‡ | 3,384,804 | −0.0196 | (−0.0525 to 0.0132) | 3,384,804 | 0.0013 | (−0.0126 to 0.0153) |