PCN Specification: Anticipatory Care

An overview of the Anticipatory Care enhanced service specification outlined in draft proposals published by NHS England.

The service is for patients with complex needs, and their carers, and aims to keep them healthier for longer by providing more proactive and joined up care across the health system and voluntary and social care sectors.

This is to be achieved by identifying the target population and establishing their needs through risk stratification and clinical judgement, and creating multidisciplinary teams (MDTs) around their needs.

The service focuses on the ‘rising risk population’, comprising those with multiple long-term conditions and/or frailty, who may have underlying risk factors like unhealthy lifestyles, behavioural risks, social isolation or poor housing. Addressing many of these risk factors will require non-clinical interventions and strong working relationships with local voluntary, community and civic groups, as well as system public health teams.

NHS England concedes there is not yet a standardised approach to identifying individuals for this service and that the evidence base is still developing. The idea is that experience in the first year will be used to develop the service model in future years.  

As such the first year of the service is basically a preparatory year, with target populations to be agreed by the PCN through discussion with their CCG and their Integrated Care Service (ICS)/Sustainability and Transformation Plan (STP).   

Proposed service requirements for 2020/21

The service specification sets out the following six requirements for PCNs:

1. From no later than 30 June 2020, present a coherent local Anticipatory Care model by:

• identifying a responsible clinical lead for delivery of the model;
• assisting with the development and improvement of system-level population health management approaches to identify patients with complex needs that would benefit from anticipatory care;
• working with others to develop and establish, clinical accountability and governance arrangements to manage the model, through shared design with providers of community services and mental health care, engaging with social care and voluntary services, drawing on existing system-level programmes where possible;
• taking a leading role in coordinating the care and support of people as patients begin to be treated by Anticipatory Care – building links and working across the system to facilitate development of a wider model of integrated care for individuals living with complex needs.

2. From no later than 30 June 2020, with CCG support, work with others to develop and sign data sharing agreements between practices and with providers delivering community and mental health services, local acute hospitals voluntary sector organisations and social care to support the operation of MDTs and the development of population health analytics data sets.

Support the development of system-level linked data sets to build population health analytics capabilities, including the extraction of anonymised, patient level data.

3. From no later than 30 June 2020, identify a priority list of patients who are at rising risk of unwarranted health outcomes, based on the CCG standard approach where applicable.

Prioritisation should focus upon:

• individuals with complex needs: including multiple long-term conditions and/or with frailty.
• those that are amenable to improvement through multi-disciplinary intervention and
• those that are at high risk of their condition progressing or circumstances or needs substantially changing within the next six months.

4. From no later than 30 June 2020, establish and manage an MDT, to meet regularly to coordinate and manage the care of the cohort of people on the Anticipatory Care list.

5. From no later than 30 June 2020, co-ordinate and deliver comprehensive needs assessments, targeted needs assessments or care co-ordination reviews for the people in this cohort, recording this activity and the person’s individual goals in a personalised care and support plan.

6. From no later than 30 June 2020, coordinate the delivery of support offers as identified by the needs assessment and the patient’s personal goals. Via the responsible lead, retain overall clinical responsibility for the delivery of this plan.

The available support offers must include (not exhaustive):

• medicines optimisation to address problematic polypharmacy, in line with the process established in the SMR specification
• social prescription using a broad range of community assets to support well-being and address loneliness and isolation
• carer identification and signposting to local support
• annual comprehensive or targeted needs assessment for other validated cohorts with complex needs.
• annual care coordination review for other validated cohorts with complex needs.
• adoption of patient activation measures
• non-medical interventions from the personalised care and support plan.

Proposed metrics to assess delivery of the service:

1. Number of individuals in receipt of the Anticipatory Care model.

2. Number of needs assessments carried out for individuals in receipt of the Anticipatory Care model.

2. Number of individuals in the active cohort of the anticipatory care model with a personalised care and support plan.

3. Number of individuals in the active cohort of the anticipatory care model receiving a falls risk assessment.

4. Number of individuals in the active cohort of the anticipatory care model receiving a delirium risk assessment.

5. Number of SMRs for the active cohort on the anticipatory care model.

6. Number of SMR follow-ups in the active cohort on the anticipatory care model.

7. Number of individuals in the active cohort on the anticipatory care model given a referral to social prescribing service or where social prescribing is declined.

You can access the full draft specifications document here.