Working with the community: PCNs on building trust

Primary care leaders joined Pulse PCN editor Victoria Vaughan to discuss how they are working with communities and building on the lessons learned from the Covid vaccination programme

Riyad Karim, Assistant director of primary care, Enfield, north London

Alexandra Kerswell, project manager, additional roles reimbursement and childhood immunisation in central London

Dr Manraj Barhey, clinical director of Medics PCN, Luton, Bedfordshire

Dr Andy Brooks, visiting fellow at The King’s Fund, GP in Surrey

Nicola Hall, transformation programme lead, Coventry and Warwickshire

Building on covid

Victoria: Following the work done in the initial phase of the Covid vaccination programme, PCNs are forging links with faith groups and the voluntary community and social enterprise (VCSE) sector. Can you outline the work that is going on in your areas?

Riyad My role is to support primary care in general. With regard to Covid, it’s been increasingly collaborative in focus, working with PCNs, the GP federation, the VCSE sector, public health, acute and community providers. Many were concerned about the disproportionate impact of Covid on black and minority ethnic (BAME) communities.

Enfield council public health team provided regular figures so we had a data-driven approach to that group, looking at vaccine uptake by age, sex, ethnicity, geography and language spoken. That helped to inform how we engaged with communities by locating vaccination pop-ups at mosques, churches and women’s centres, for example.

We also mobilised trusted faith and community and clinical leaders because it was clear that underpinning vaccination was the need to engage with the community on health inequalities, particularly with the black African, black Caribbean community. That ensured that when we did webinars and community engagement, we focused on particular languages or ethnicity groups. We’re continuing that work into childhood immunisation, using trusted voices and trusted leaders in the community and clinical leaders.

Alexandra When Covid vaccinations were launched, we worked closely with our volunteer networks, not only as a workforce but also by acting as prime examples of why to get a vaccine. By volunteering at the sites, they became spokespeople for it, which was really interesting to see. We had staff who were administrators, who were anti-vaxxers at the very beginning but then by seeing herd movements, began to say: ‘Actually, I’ll do it’. They went on to speak out in newsletters and their local communities.

Our social prescribers initially worked on site, and so they had all the information and could speak with confidence. We had marshals from learning disability charities, which helped when patients came through the doors.

We moved the site around once pop-ups were established into local places of faith. We had a bus and we put a call out to anybody and everybody who had ideas and wanted to be involved. Because everyone had been behind closed doors for so long people jumped at the opportunity, which was amazing to see. There was a real strong sense of community, especially in the first few weeks. That has continued as some of the volunteers that still work at our vaccine sites are people who attended to get a vaccine.

Manraj When we were tasked, as PCN, to set up vaccination centres, we hit the ground running and had lots of input. But regular monitoring showed that the uptake in certain communities was low. We were approached by local leaders so GPs put together little video clips encouraging vaccination.

We put some of the local clinical leaders on local radio. A community vaccination hesitancy group was set up very quickly. We were asked do an outreach clinic at the local Sikh temple and the mosques.

We found if we used our local leading clinicians and religious leaders, advising people to have the vaccination, and showed them on video having the vaccinations done, the uptake improved considerably.

In Luton, one of the lesser-known factors is that a lot of unregistered patients are here illegally. I remember the first trip to our local mosque. We had about 200 patients turn up who weren’t registered with any practice, the people with no papers. They all wanted their vaccination but they had nowhere to go because they weren’t registered. We had a similar experience at the Sikh temple. Very quickly, we built close relationships with the local religious institutions. That’s carried on. They’re asking us: ‘Please can you come and do health checks and blood pressures and so forth?’ Obviously, the Government’s amnesty on unregistered patients helped, so we were allowed to just vaccinate and there were no questions asked.

Trust

Victoria: This idea of trusted voices and using your volunteers as advocates – can it be applied to delivering other services in primary care?

Manraj Absolutely yes. We’re getting demands and requests, saying, ‘Please come back to our Sikh temple’, and ‘Please come to our mosques’ to do health checks and education and so forth. The downside is this is all out of hours and there’s no funding for it. We’ve done a couple of visits to the Sikh temple and the throughput is amazing. All the people turn up wanting their blood pressures and blood sugars done and so forth, but the common theme is poor access to primary care.

The topic of discussion has moved on to less common things. We’ve done something at the local Sikh temple on autism. A few years ago, you wouldn’t hear of these sort of things at a Sikh temple – it’s had a really positive impact.

Alexandra Yes, just to reinforce what Manraj was saying, in our area, it has enabled us to move quicker with things like polio, and the work that I’m doing with our pilot on childhood immunisations, which involves working closely with the community to improve uptake using community settings. We’re trying to apply the same approach in building up conversations about vaccinations for children, getting people talking about it and feeling confident to talk about it. The more people we can reach with correct information and the more people we can train to articulate it appropriately, the better healthcare and access become.

Covid was a fantastic opportunity because things were made a lot easier, especially with access to information and working together. Some red tape became a bit orange, so you could get around things much quicker. That was really good, but before that, in central London, our PCNs had been working with the voluntary sector and communities, in terms of engagement and training, with people such as carers’ networks. They’d come in and offer training at practices. We had the learning disability charities. We had an initiative called Pride in Practice. Opening these doors to these trainings, [which] weren’t mandatory
but were things that improved relationships and referrals and built on how they could be referred into – that led to social prescribing.

We also have volunteers that work in the GP practice gardens. If patients feel like their practice is theirs, they know the staff, they belong there, they’re more likely to engage appropriately with it.

Andy Nationally, we wanted lots of people to be vaccinated but there wasn’t a target. Lots of stuff came from the bottom up, which I think [makes the success] really interesting. The cultural stuff and the soft stuff was really important, and it focused on one-to-ones. All the individual success stories add up to population bases rather than a top-down approach.

There’s also capacity and capability – as Manraj was saying, this was done outside core stuff. It was people putting in effort, which is great – but if it needs to be extended, it’s going to require significant capability and capacity.

There is also a potential that we underestimate the risks of more complicated [tasks] and therefore require even more capacity. While the effort that went into [the vaccination programme] was significant the task was straightforward.

Riyad In terms of legacy work we discussed about how particular MDT groups we’ve used during Covid vaccination can now be used for polio and childhood immunisations. One of the things that became clear, particularly when we worked with our black Caribbean and black African communities, was that we needed to invest more in programmes to address health inequalities with the communities.

In response to a community consultation, we commissioned a specialist organisation called the Caribbean & African Health Network (CAHN) from Greater Manchester, using inequalities funding, to set up this programme for Enfield Primary Care. It was intended to address health inequalities and was overseen by our communities director. It delivers a one-hour session of culturally appropriate education, training and support, designed for Enfield Primary Care staff and other healthcare professionals. It’s free for Enfield practices and is endorsed by CAHN, and has been quite transformational for practice managers.

Many [practice managers] have said they thought they’d understood diversity but [this has] shown that they need to know the local population more and need to be engaging more – which is mind blowing.

Manraj The PCNs do tackle health inequalities, or are certainly trying to, in terms of finding CVD, hypertension, cancer and so forth. Having learned lessons from the vaccination programme, we have used some of our additional roles to look at aspects where we can try to help.

As an example, we’re doing a lot of work on hypertension case-finding and CVD risk. We’ve got our physician associates doing the actual work, taking blood pressures and so forth. We’ve got care co-ordinators getting the data and we’ve got our social prescriber and health and wellbeing coach targeting various communities that we know are at risk. It’s their day job now to build up their relationships with local communities. Occasionally we have to do things out of hours in terms of education but we must not forget that PCNs are an enabler to tackle some of these health inequalities and carry on some of the work we’ve established from the vaccination centres.

VCSE sector

Victoria: The VCSE sector is also working with PCNs to provide support in areas such as mental health. Can you outline how that’s working for you?

Nicola In Coventry and Warwickshire I’m part of the community mental health unit at Rethink Mental Illness, supporting the transformation in local areas. Also, I’m the local lead for Coventry and Warwickshire working with the PCNs, particularly the social prescribers and the mental health liaison workers and link workers. I’ve been developing multi-agency MDTs. There are lots of organisations that attend – housing, social care, secondary care, psychology, the police and probation. A common theme in primary care and the voluntary sector is the level of complexity of some of the cases we’re working with – that either aren’t getting through access hubs into secondary care or are on huge waiting lists and therefore are relying on primary care and the voluntary sector.

These multi-agency MDTs are bringing all the partners together to work through some of the complexity and [develop] a fast track into secondary care for the patients who should have got through the access hub. Also, [it is helpful to] bring together the professionals to work in an aligned and co-ordinated [way] as patients are working with so many different professionals they almost become their own care co-ordinator trying to align all the different types of support. Multi-agency working is really about providing this aligned support, which is being delivered throughout PCNs in Coventry and Warwickshire.

Victoria: Alexandra and Manraj do you have multi-agency MDT teams for your PCNs and someone co-ordinating this?

Manraj The short answer is no. One of our biggest frustrations is that there are lots of good pieces of work going on in the community but we don’t actually know about them.

Let me give you a couple of examples. We set up a health check in our local Sikh temple and while we were there they were saying, ‘Somebody’s contacted us from public health and they’re coming in a month’s time’, which was the first I’d heard of it. I went along to the event and I asked the people doing the health checks ‘Where do you record the data?’ They said, ‘We just put it on some bits of paper somewhere’. It wasn’t going to the practices or PCNs. The work is going on but not being co-ordinated. The information isn’t being recorded centrally. We need a lot more co-ordination between the big stakeholders, public health and community trusts so we can tap into them and work alongside them rather than reinventing things.

Alexandra We’re fortunate in central London that our GP practices and the PCNs were working in these. Sadly there isn’t one individual with an MDT hat and there are multiple teams – name a target group and there is an MDT [for it] somewhere.

One of the things that was identified recently with my childhood immunisations project is that family navigators weren’t involved in some of the children’s MDT meetings and they want to get involved. It’s by having these conversations in pilot projects that [we get]the people involved that should be.

There’s no resource for this. It is purely funded by the passion of the individuals. If we look at primary care, the amount of time that is volunteered beyond individuals’ roles is phenomenal.

At the moment one of our focuses is high-intensity users. There are a couple of different projects going on and we’re drawing on volunteers and the community to take responsibility for high-intensity users. At the end of these pilots we will hopefully show they have had an impact.

One of the pilots is a demonstrator that is identifying pools of people that are accessing services or [might] access more services. We’ve got about 900 young people across the borough that we’re going to be targeting to make sure they are better supported in accessing healthcare and are being socially prescribed.

However, one thing that we are at risk of doing, especially in central London, is having nowhere to socially prescribe to.

By increasing all this access and awareness, the services are floundering because their funding isn’t as strong as it used to be and they don’t have the provision.

Victoria: Nicola, how is your MDT funded?  

Nicola My funding comes from the Rethink Mental Illness charity’s aid foundation to support the transformation. Basically my role has three prongs: I work with the voluntary sector; I sit on all the transformation boards; and I co-ordinate and develop MDTs. Sometimes there’s an assumption that if you refer a patient to a service they are actually getting that support. In fact, that patient may be on a huge waiting list or that service may have gone – this is an area where the MDTs can definitely help.

Victoria: How do you make the information on community provision more available to PCNs?  

Andy One of the things I found really helpful as a GP is not having to be aware of what the services are. What I try to convey is the patient’s need rather than deciding [what service they should go to]. Then the experts who have a directory can [direct to the most appropriate place].

Manraj There’s something to say about building [community provision] into the local structure. We’ve got a place for health inequalities, which is funded by the integrated care board [ICB].

For example, we have social services, public health and the mental health trust and it’s built into the governance structure so that they are aware of what’s going on, which can be fed back to primary care and other PCNs.

Future

Victoria: What would help you capitalise on working with the VCSE sector? 

Manraj We need shared data because we find that different stakeholders use different systems. They can’t talk to each other. The data Public Health provides is usually out of date and again, it can’t simply be transferred to GP systems.

Also, [it would be good to] share knowledge of the resources available to us. Half the time, we don’t know what’s going on in our own neighbourhood. We need to get on with this and actually do things.

I’ve been [at] clinical commissioning groups (CCGs) and, prior to that, primary care trusts (PCTs) for so many years and I’d like to see outcomes and results. I think PCNs are a huge opportunity to [tackle] bite-sized chunks with measurable outcomes fairly quickly.

PCNs can be a huge resource for workforce. They can tackle health inequalities directly and we can measure our own data. From the more strategic point of view I like the phrase ‘fusing strategies’. If you look at the local police strategy and where the most stabbings and burglaries take place, it almost mimics health inequalities maps. They’re all targeting resources to the same area – so let’s all join forces rather than work in silos.

Alexandra We need investment – not only in the services themselves but in people that help develop and oversee it. We’ve got lots of investment in things such as social prescribers and care co-ordinators. These roles are good and useful but there’s nobody to manage and direct them. Some investment in supporting the networks is needed – and that goes beyond just PCNs and the GPs but into the wider community with volunteers to continue the legacy work that Covid brought.

There was a really interesting psycho-social phenomenon during Covid that hasn’t been seen for a long time. Although there was an increase in mental health problems from isolation, there was a decrease in certain types of mental health problem because people engaged in things they enjoyed where they live.

It would be helpful to have investment in a workforce that can look at that, pull it together and learn from it.

Riyad The structure is important but underpinning that is the level of coproduction and relationships. [We need to]build trust, internally and externally with all the stakeholders in a borough.

Also levels of deprivation must be accounted for – and I would hope that funding will be prioritised on the basis of deprivation in the area.

Certainly during Covid, hyperlocal funding was allocated on that kind of basis. That helped to co-ordinate and target vaccine promotion.

It’s important to recognise that across England, we’re in the transition model. We have ICBs – they’re in transition as prior to that there was a CCG, which was a primary care-led organisation. Now we’re moving towards a multi-professional integrated care system and an organisational structure.

It’s important for me to amplify the impact of primary care and PCNs. We’re not clipboard commissioners and we haven’t been for the last two or three years. [This is all] about partnering and partnership working and ensuring we help and support primary care in this transitional process. Looking at the Fuller Stocktake, that’s going to be very important in the future, in the promotion of integrated neighbourhoods.

Above all, it’s all about building relationships and trust – as we’ve been saying all along.