How this PCN uses Patient Health Teams

Earley + PCN in Reading is one of the 10 networks shortlisted for PCN of the year. It has leveraged patient segmentation tools to develop and implement a Patient Health Teams (PHT) model, which has improved continuity, reduced clinician administrative burden, and enhanced patient outcomes. PCN transformation manager Natasha Poller and senior transformation manager Sarah Simpson explain more.

At Earley + PCN, continuity of care was a challenge despite being a single-practice PCN due to the size of the organisation – 31,000 patients across four sites. We also wanted to make better use of appointments and improve patient outcomes without adding to clinicians’ administrative burden.

We developed a Patient Health Teams (PHT) model, in conjunction with a population segmentation tool developed by Connected Care using the Johns Hopkins Adapted Clinical Groups alongside Anima online consultation software, to achieve this.

Segmenting patients

Patients were assigned to coloured segments according to their complexity and need, with red indicating those with the highest needs and green indicating those with very little need based on the likelihood of admission to hospital in the next year.

With historically high consultation rates and frequent attenders, we initiated quarterly reviews of patients who had four or more routine appointments or six or more urgent appointments per quarter. Before launching the model, we identified 979 patients with 10 or more annual GP/physician associate (PA) consultations.

Taking this proactive approach allowed us to tailor interventions and manage patient demand more effectively. And by re-evaluating this cohort annually, we monitor impact and adapt strategies for sustained improvement.

The PHT model assigns each patient to a usual care team comprising a partner, a salaried GP, a physician assistant, a social prescriber, and a patient services liaison. This structure ensures consistent care delivery and proactive patient engagement.

For example, each team holds a monthly meeting to review their red (high needs) patients, ensuring everyone is aligned on care plans. The patient services liaison provides regular, non-clinical touchpoints for these patients, addressing ongoing needs and reducing the reliance on frequent clinical appointments.

Complex patients remain under their usual team’s care, while lower-acuity patients are directed to our urgent care team - a team composed of paramedics and nurses who typically see green patients on the day for less complex needs, such as UTIs.  

Patient teams

A driver for this model was to reduce the administrative burden on clinicians, so we trained members of our reception team to serve as patient services liaison staff. These receptionists received additional training to complete more complex tasks, such as requesting blood tests or processing simple referrals requested by the clinician, while working closely with their team.

By integrating a social prescriber within PHTs, we make better use of voluntary and community resources and signpost patients more effectively. This also enables a more holistic approach to care and facilitates lifestyle changes that support patient wellbeing.

Training and ownership have been crucial. Having a GP partner lead each team has provided overall responsibility and ownership. The partners talk to each other to ensure a consistent approach across every PHT, as well as to identify any specific training needs. We hold regular patient services liaison meetings, allowing team members to raise any training needs or questions.

An important consideration was the number of sessions available in each team per registered patient. We looked at the number of face-to-face appointments provided by each team, total patients and patients by segment. This enabled us to ensure parity across the teams, as well as ensure each team had an appropriate number of sessions for the patient list.

Approach

We have found that working together regularly greatly increases team efficacy. It enables more effective communication and allows team members to support one another with complex cases. Where possible, we have ensured teams are composed of clinicians working at the same sites to encourage this approach.

Working closely with Anima, we embedded segmentation at the point of triage. This allowed us to prioritise patient requests based on symptom urgency and individual complexity. As Anima has a self-book function, we can invite patients to book a routine appointment with their PHT. This means patients are seen by the most appropriate clinician within a reasonable timeframe, at a convenient time for the patient.  

Communication with patients was integral to the success of this project. To secure patient buy-in, they needed to understand why we were taking a new approach. We created a leaflet explaining how PHTs work and the difference this would make to the patient, and how they interact with the practice. Staff also reinforced the value of PHTs, encouraging patients to continue seeing their team, even when that meant waiting longer for an appointment or consulting with a clinician who isn’t a GP.

Outcomes

Since introducing PHTs, continuity has increased significantly and remained high. From 36% at the start of the project, continuity has reached an average of 65%.  For the 979 patients with more than 10 appointments before the project, we found a 41% reduction in the number of appointments. This equates to saving six months of a full-time GP's sessions (based on eight sessions a week).  

We have been able to utilise appointments more effectively by reducing consultations with green patients and increasing the use of appointments for red patients.

There has been a positive impact on secondary care too. We have seen a significant reduction in A&E attendances from green patients - a 10.3% drop - and overall admissions to hospital from our population have decreased by 3.1%.

Implementing the PHT model has also increased job satisfaction. Working in small teams gives clinicians a greater sense of ownership for patient care and provides additional support for complex cases. Clinicians can work at the top of their license, while patients are matched with the most suitable team member. Teams also benefit from peer learning when discussing patient care rather than working in silos. This builds resilience, as staff feel supported and have clear accountability. The approach fosters organisational stability through cross-cover and a shared workload.

The PHT approach at Earley+ PCN exemplifies how intelligent design and collaboration can improve care quality, optimise resources, and create a more sustainable general practice model.