Modern General Practice working – A population health approach Foundry PCN

Foundry Healthcare Lewes is a single Practice Primary Care Network made up of 4 surgeries in the Lewes and Ringmer area of East Sussex.
The Practices initially came together through their involvement in NAPC’s Primary Care Home programme and their collective vision to create a
more preventative, proactive and integrated approach to managing their 28,500 patients.

Foundry introduced a methodology for segmenting patients according to their clinical need/social complexity and prioritising continuity for those
patients who need it most. They found traditional search-based approaches time consuming and retrospective and therefore developed their own
tool, creating a real-time, clinician-led system where patients are dynamically categorised as Red, Amber, or Green at the end of each
consultation. This simple yet powerful model (can be integrated with Systmone and EMISS) allows practices to proactively manage continuity of
care, engage the whole team in decision-making, and improve outcomes for both patients and clinicians.

Foundry operates a centralised clinical hub for triaging patients and meeting urgent on the day pulling in a range of multi -disciplinary professionals
embedded within the team. This includes in-house paramedics, physiotherapists, mental health workers, clinical pharmacists, social prescribers
and they also work in an integrated way with acute physicians, third sector organisations, community health and mental health providers. They
are about to launch a pilot project integrating the Ambulance service with their extended frailty team. Red/Amber patients a nd those Green
patients requiring episodic continuity, rather than being dealt with in the hub, are seen at their registered site with their named GP or another
member of their site based team familiar with their background.

Foundry has since introduced Modern General Practice Model in its entirety including full (6.30am-6.30pm) on-line consultation since April 2024.
This comprehensive understanding of demand now enables a far more intelligence driven, needs based and strategic approach to meeting need
and planning/optimising practice capacity. To this end, Foundry has created a data insights dashboard which pulls together information across
the range of operations including website traffic, phone lines, on-line consultations, clinical appointments requested and given, continuity and
access metrics.

Foundry has also introduced a culture of continuous improvement, GPs and other clinicians are allocated weekly management time to lead on a
range of clinical quality improvement programmes based on annually agreed priority areas such as frailty, diabetes, CHD etc. Training including
in QI methodology, project management and change management qualifications are offered across the whole Foundry team.