How this PCN… tackles health inequalities

Healthy Hyde PCN is one of the six networks shortlisted for PCN of the year. Clinical director Dr Jane Harvey shares the PCN’s work on tackling health inequalities

Tameside, Greater Manchester, is one of the ten poorest communities in England. In the town of Hyde, male life expectancy is five years lower than the UK average; it is six years lower for women. Half of our PCN population belongs to the poorest quintile and, despite many previous well-meaning efforts, this is our status quo. So, Healthy Hyde PCN looked at what we could do to change this.

Our practices had already worked collaboratively on various projects prior to the formation of PCNs. These schemes included social prescribing, local housing, and voluntary projects. When we formed, we chose to use our existing unity of purpose to focus care on a population basis to tackle health inequalities.

We recognised this would require us to work closely and integrate with an array of pre-existing services in the area such as: the job centre, Welfare Rights, Citizens Advice, housing, domestic violence services, drug and alcohol services, the Alzheimer’s Society, schools and food banks. We reached out to these organisations and, thankfully, they were just as keen as we were to integrate and work cooperatively.

Healthy Hyde PCN educated itself about how disadvantaged groups absent themselves from health services due to fatalism or normalisation of their symptoms and a fear of being blamed. We learned how, if they do seek help, services tend to be blunt and inflexible. So, we provided services that listened hard to such groups and had no exclusion criteria.

Key to this is the holistic conversations our 10 health and wellbeing practitioners have with people they case-find (by attending food banks and groups that target loneliness and isolation) or are referred to us by the agencies above.

These holistic conversations are used to write personalised care and support plans and enable effective social prescribing. We attend all the food banks in our area with a GP and a mental health practitioner on a weekly basis. This ensures that those who are struggling to access healthcare have it placed in front of them. These are usually the people who need access to healthcare the most.

Uptake gap

Our vision for reducing healthcare inequalities was shaped early, through presentations delivered to us by Prof Chris Bentley, the former head of the Health Inequalities National Support Team. He encouraged us to understand the ‘uptake gap’ – that is, why people in disadvantaged communities only buy into their health when in crisis.

Prof Bentley asked us to consider the misalignment between the priorities and competencies of our population and the organisation of health services. National guidance directed us to Core20PLUS5, but we knew this concealed a subgroup: people who would never accept health screening invites and whose data (or absence of) masked their true vulnerability. We had to think imaginatively, but the answer turned out to be old-fashioned – develop a personalised needs-based approach.

Our local partners understood our pitch and recognised the virtues of integrated working, so we pushed through half-opened doors. We knew our local voluntary sector from previous joint working, and our local authority public health department was keen to give granular data to facilitate analysis of our population needs.

Our local foundation trust was already exploring integrated working through joint access to care records and providing a digital health in-reach to our care homes. We meet with these colleagues regularly, but we also seize opportunities to work with them whenever we can, such as delivering an NHS Health Education England CLEAR project on anticipatory care for patients with dementia where key stakeholders came from health, social care, mental health and the voluntary sector.

Action

Good communication and the flexibility to break out of silos is vital if individual care plans are to have validity. So, when our patients describe housing, domestic violence or social isolation needs, we all look to move quickly from ‘no man’s land’ to a solution.

In practice, this means having tenacious care coordinators who cut their teeth on the challenges of the Covid vaccination programme and do not readily accept a ‘no’ answer. Some unlikely partnerships for a health provider have emerged, as a result.

For example, one has liaised with our local authority refugee coordinator to provide English lessons/social integration for displaced people on college official waiting lists. And our children’s wellbeing practitioner works across 20 primary and secondary schools, delivering wellbeing interventions to 140 children weekly, looking particularly at behaviour and school absence.

Healthy Hyde PCN Outcomes

Data for 2023 shows more than 2,500 completed care and support plans (109 from food bank users, 94 from English classes) and a further 147 holistic contacts – where care and support plans were not completed. We also have more than 3,000 additional referrals to social prescribing. We also found more than 50 people who were not registered with a GP.

Our young person’s wellbeing practitioners work one-to-one with over 140 children per week. And active case-finding through spirometry clinics (512 attendances) uncovered 77 new COPD diagnoses and 104 hypertensives, while 180 attended the Beating Heart clinics for blood pressure monitoring and treatment. All had onsite access to BeWell, our local authority lifestyle coaching provision.

We are particularly proud of our HealthyHyde.com website, which is our patient-facing means of communication with our population. It is an adaptable pictorial information platform, updated by the team, with calendars for groups and events, and a patient-generated care and support plan that can be emailed back and added to EMIS notes. It also hosts local dementia resources for practitioners, patients and carers.

Our anonymous feedback form showed 89% were satisfied or very satisfied with their experience and would recommend our service to their friends and family.

At the heart of all health and social care interventions is a belief in the power of individuals to change their behaviour, but it can be hard to sustain with over-stretched and under-resourced services. We believe that the individual success stories generated by our project sustain other areas of the Healthy Hyde PCN team in their work and inspire our wider health economy.

Dr Jane Harvey is clinical director of Healthy Hyde PCN.  

The General Practice Awards are run by Cogora, the publisher of Pulse PCN. These awards highlight innovation in primary care across the UK. This article is part of a series on the shortlisted PCNs.