The main objectives of the Greater Manchester Proactive and Personalised Care Programme were to:
- Improve management of high-risk and long-term conditions
- Use data to identify, stratify, and proactively engage patient cohorts
- Develop PCN-level approaches to support sustainable care transformation
- Build capacity through workforce development and community partnerships
A total of 26 PCNs completed the programme, from an initial cohort of 30, and PCNs faced numerous challenges along the way, including workforce issues, limited capacity within teams, engaging with communities, access to technology, quality of data, and skills to interpret data.
Despite the challenges, PCNs worked hard to overcome them and embraced what the programme offered in terms of health coaching and guidance, practical QI tools, and support with data identification and analysis.
Each PCN celebrated individual achievements within their project, such as:
- Higher levels of engagement and attendance
- Increased identification of cases
- More testing and referrals
- Better relationships with community partners
- Development of workforce roles
- Education and empowerment of patients
- Established new models of care
The overall success of the programme was assessed based on its alignment with GM priorities, achievement of objectives, efficient use of time and resources, impact on people’s health outcomes, and its potential for long-term success.
While there was variation across PCNs, we concluded that using a data-driven, community-engaged, and iterative approach achieves better patient outcomes.
We would like to develop the proactive and personalised care programme model into a pillar of population health transformation across Greater Manchester, with the appropriate support and some minor adjustments.
