How the Predictive RIsk Stratification Model risk tool was planned and developed across Wales
This section presents results of interviews with policy-makers and health services managers (n= 12) responsible for chronic condition management in Hywel Dda, Betsi Cadwaladr, Powys, Cardiff and Vale, Cwm Taf, and Aneurin Bevan Health Boards.
Interview respondents reported broad support for the introduction of a risk prediction tool in Wales. One commented that, at a Wales-wide meeting,‘there was a complete consensus’ (PHB06) regarding the tool’s development, driven in part by a focus on reducing emergency hospital admissions:
We’re demonstrating at the moment about 8–10 per cent increases in emergency admissions year on year. So, it’s completely unsustainable, but it’s massive pressure on hospitals and we have to do far more to stop people coming in.
PHB01
We knew that we had to look at these patients who were multiple admissions to hospital, and that there was a keenness to stop people going into hospital, and to keep them in the community, and keep them at home.
IPHB09
I think it’s critical. You should be able to plan, as far as you can, and try and understand where your demands for health care are going to come from.
PHB07
Several respondents recalled that PRISM had been anticipated for some time. They indicated that there were high levels of awareness and enthusiasm across different staff groups with a strategic interest in chronic conditions management:
. . . there’s strong support amongst the audience, primarily the local health board, chronic condition [staff?] and managers, planning implementation manager, they like the tool, want it, and were . . . quite keen to say‘well – but when are we going to get it?’
QOF start 1 April 2013 QOF end 31 March 2014 5 15 25 35 45 55 (weeks) Practice 30 Practice 13 Practice 20 Practice 5 Practice 6
Practice 4 Practice 8 Practice 2 Practice 21 Practice 29 Practice 32 Practice 19
Practice 11 Practice 23 Practice 26 Practice 15
Practice 18 Practice 10 Practice 28 Practice 17 Practice 31 Practice 9 Practice 7 Practice 12 Practice 22 Practice 3 Practice 24 Practice 14
Practice 25 Practice 1 Practice 16 Practice 27
FIGURE 6 The timing of mid-trial interviews with participating GP practices in relation to the QOF reporting deadline.
STAKEHOLDER VIEWS: THE PREDICTIVE RISK STRATIFICATION MODEL IMPLEMENTATION AND USE NIHR Journals Library www.journalslibrary.nihr.ac.uk 74
The work that we did on chronic conditions management when the national framework came out was very much sort of looking at an overview of services overall . . . Within that we’ve always been waiting for PRISM . . . because we always talked about‘when PRISM comes we’ll do that’.
PHB10
Most respondents were aware that PRISM had initially been proposed as a tool to support the planning of services. A minority of respondents expressed the opinion that this original vision was preferable to the subsequent emphasis on use within GP practices:
. . . the original concept was based . . . on population, managing the needs and allocating the services and support more appropriately to meet those needs . . . [. . .] the original concept was that it was a locality tool that we could use to kind of do a population-based planning . . . and we got sucked down into the primary care individual level.
PHB03
This scepticism about the role of the tool in case finding of at-risk patients at practice level could be linked to the attitudes that respondents reported observing in some GPs at the time of the tool’s development and piloting. Though some interest and openness to the tool was reported, respondents also identified many aspects of caution and reluctance among GPs and practice colleagues. These included comments that: l PRISM was a threat to professional autonomy:
. . . this way of working is not one that many people are comfortable with, because it takes the initial responsibility of identifying people away from clinicians. And I think that that’s quite difficult for many people to come to terms with.
PMB06
l there was a lack of evidence to justify it:
Some of them would say,‘I will use it when I know more about it, when it’s more developed, when it’s more understood’. . .
PMB02
l it would not provide new or timely information on patients:
The first thing that practices were coming up with was,‘Well, we know who our top patients are, we know who these patients in the top of the pyramid are, why would we need a piece of software to do that?’ And it was actually trying to explain to them the concept of not just looking at those patients who you knew were very ill, and were likely to be experiencing admissions, but it was those people who were further down the pyramid, but starting to fall over into a higher need bracket.
PMB09
l it would generate additional work.
Constraints on implementation pre PRISMATIC
Several respondents reflected on the constraints on implementation of PRISM shortly after its development. They reported their perception of the reasons at national level for the delay in Wales-wide implementation. These reasons related to concerns about the accuracy and value of the tool; concerns about confidentiality and patient security expressed by professional body representatives, including the British Medical
Association (BMA); a lack of central ownership and top-down drive to continue to develop and promote PRISM; and a lack of GP champion to provide peer support and encouragement:
I think public health [representatives] didn’t have enough confidence that it [PRISM] was accurate; they have their own parameters. GPs and the Welsh BMA, they had concerns about: was the supporting infrastructure around confidentiality and patient security enough?
It was the BMA in the end who . . . had enough reservations that prevented us from making it more widely available.
PMB03
There was no new development work, there was nobody really we could say was a PRISM person. [. . .] which is a shame, because we invested a lot of effort initially to it and then suddenly it just died.
PMB05
There’s no other way GPs will engage, they will engage more with their own colleagues initially.
PMB08