Tackling health inequalities: How PCNs are working with inclusion health groups

Inclusion health groups, which are part of the Core20PLUS5, cover socially excluded people who typically experience multiple overlapping risk factors for poor health, such as poverty, violence and complex trauma. Three experts join editor Victoria Vaughan to discuss the approach taken by different PCNs.

Dr Shanika Sharma, clinical director and health inequalities lead, Barking and Dagenham PCN, London

Dr Sian Stanley, clinical director, Stort Valley and Villages PCN, Hertfordshire

Dr Prema Ravi, clinical director, Orpington PCN, Kent (October 2019 to February 2024)

APPROACHES

Victoria Vaughan (VV): PCNs don’t have a remit to cover these health inclusion groups but many have built on the success of Covid vaccination programmes where there was outreach to vulnerable groups of patients. So, what’s your PCN’s approach and what communities are you working with?

Shanika Sharma (ShSh): A couple of years ago, the PCN worked with the public health team and our voluntary sector colleagues to put in a bid for Northeast London ICB health inequalities funding.

Barking and Dagenham has one of the highest levels of deprivation nationally and we managed to secure the maximum amount of funding available.

That allowed us to develop a bespoke programme to look at tackling health inequalities across the borough. We were able to appoint a health inequalities lead per PCN and a clinical director for across the borough. It allowed us to have dedicated working on this, and we’ve slowly built on that infrastructure. In parallel to the PCN health inequalities leads, who are all GPs, the voluntary sector also recruited locality leads. There was a lot of synergy in these two leads working together in a PCN footprint.

And we realised that these inclusion groups are not very forthcoming to primary care so we started to go out to them. We’ve had several pop-up events targeted at homeless health, for example. Through the pop-ups, we realised that seeing a GP wasn’t the first thing these individuals wanted. They wanted to be showered, fed, have their hair done, and then have a conversation about health.

In February half term, we held a borough-wide health and wellbeing pop-up and we had 7,500 residents of Barking and Dagenham attend. It was for everyone – not just homeless people – but we didn’t expect that number. It was raining – literally chucking it down – but there were people queuing outside.

We were doing height weight measurements for children because we have a high rate of childhood obesity, women’s health, and men’s health. The longest queues were for the hairdresser and for the food we provided. It was just really nice to meet and interact with people who might not be forthcoming.

We’ve also done quite a lot of work on immunisations, especially with the Gypsy Romanian community. The ICB has kindly secured funding for this work for another three years so we can continue to build on it and learn what works and what doesn’t. There’s a lot of mentorship, co-learning, and co-designing with our residents.

Sian Stanley (SS): We decided to look at our young homeless population. Our area is reasonably affluent, but we’ve got a lot of unseen homelessness. There’s very little social housing in the area and the rents are so high that it’s difficult for people so there’s a lot of sofa surfing.

The local council gave us some money and our children and young people’s team went out to the YMCA. It’s been a slow burn, but an amazing journey, looking at mental and physical health within the homeless community. The dental van has parked in the local carpark so the homeless population can get their teeth checked. And we’ve been looking at vaccinations, access to health care, prevention, and drug and alcohol services.

They’ve expanded that to an all-age pathway now where there’s a night shelter that opens up over the winter locally. That’s been slightly less successful because it’s a group that’s difficult to engage for multiple reasons. But the children and young people’s side of things has worked really well.

The council have awarded us a grant for another year to keep going. Good food is very popular so we use the money to buy food to bring people in. And, like Shanika said, if you ask people what they want, it’s hair and food, and mental health support. So, if we’ve got money left over, we will fund sessions for therapy and counselling for some really traumatised young people. There’s a reason why they’re homeless, and some of the stories are very difficult to hear.

Our GP federation has a charitable arm and we put some money aside every month to fund counselling or mentoring sessions for young people.

We did a borough-wide health and wellbeing pop-up, and we had 7,500 residents attend.

Shanika Sharma

Prema Ravi (PR): We have a high elderly population. In July 2022, we saw from the data that the elderly population were still reluctant to come to GP practices post-Covid. So we invited people aged 80-plus who have not contacted the GP practice within the last two years for a health check.

And to address social isolation, we opened a café that’s linked to the GP practices. It is still going and runs at maximum attendance.

The clinical pharmacist comes in, and it’s an opportunity for medication reviews, blood pressure checks, and diabetic reviews. It’s run by our social prescribers and the care coordinators who can signpost them to other services. Other stakeholders come in too, such as the voluntary sector, and we run exercise, counselling, yoga and mindfulness sessions. We always finish with bingo, which is more popular than anything else. It’s all the community coming together in the local church where the café is located to provide this service.

Based on this, we bid for health inequality funding and now we’re working with our community provider Bromley Healthcare and the neighbouring PCN to provide anticipatory care or case management where a patient needs more attention. The aim is to prevent hospital admissions.

After the cafe’s success, the council approached us and asked if there was anything we could do for the carers. Carers are not in Core20PLUS5, but they are an inclusion group in a way. So, we opened a carers’ café, which happens every other week and is also well attended. They like it because they’re all in the same boat. This happens because of ongoing funding from our borough.

Then I received an email from the Armed Forces organisation who had identified that we have more of a veteran population than other parts of the country. They said it’s probably about 3% of the population, which is about 280 in my list. At PCN level, it’s about 3,000.

Now, we are proactively finding this cohort. Every male who is 80-plus – because most of them are male – has been sent a text message and asked if they served in the Army. Even if they served just one day in the past, that’s enough to go on to this cohort. The reason is that they have a lot of health issues including mental health issues such as post-traumatic stress disorder, and they don’t want to come to the GP, as freely as other people access the service. They always say, ‘I’m wasting your time’.

We have identified about 50 at the moment. They get a kind of priority service in primary care – not just GP services – and also secondary care. And this support is for the spouses as well.

ENGAGEMENT

VV: Engagement can be a real challenge with some of these groups. Could you talk about how you go about it?

SS: So much of this work is about relationships and trust. There’s a lot of suspicion about why we’re there, especially if there are substance misuse issues.

We go to the YMCA, the local homeless shelter. Our social prescriber, Ben, will go down there and have a chat. As a social prescriber, he’s in a unique position because it’s not a threatening role and we can afford to give him the time to work up those relationships. He says that fish and chip night at the homeless shelter is the only time that anybody talks to him, but those nights are very popular. He will make sure that they’re registered with a GP, that they can get an appointment with us and access the services that are appropriate for them.

We also have a drug and alcohol worker and a mental health worker who works with us in practice so people can come and visit Ben there if that’s what they’d rather do.

But the thing is that you have to spend ages doing this. He’s been going for 18 months. They’re not street homeless, but they’re not a group that will immediately come round and access health services. There are some really traumatised people in this group and it takes a while.

For example, Royal Free Hospital came down to do liver function tests on everybody who wanted it and they ran checks for Hepatitis A, Hepatitis C and Hepatitis B. Ben said he was surprised at how many people actually turned up because that took a lot of trust. And they came because he asked them to come. If the Royal Free had just turned up, they wouldn’t have done it.

ShSh:  Northeast London has a homeless health working group and our health inequalities leads have been working with them. They’ve done some work to identify the barriers. They’ve actually asked a group of rough sleepers: ‘What is it that it’s stopping you from reaching out?’  And it’s a fear of stigma. Someone actually said that the GP environment can feel hostile and uninviting.

One of the suggestions was a one-stop shop where you can get all your issues sorted out because they don’t have the one issue, you know? There was mention of access to pain relief services, support with mental health, and also peer advocacy, which would support people to engage with services and help build trust.

Staff training was another point. It should involve cultural competency, trauma-informed care, and awareness about sexual exploitation because we do have a lot of women and men who have had to be involved in sex work, and it’s really impacted them both mentally and physically. It brought up lots of things about the LGBTQ+ community as well such as offering bespoke services for them to address some of the barriers that people are facing.

And it’s really important that we address these barriers because we know that the mortality of homeless people is, on average, 30 years earlier than those in stable accommodation, which is quite staggering.

 So much of this work is about relationships and trust

Dr Sian Stanley

PR: With the PCN cafe, we proactively approached the patients and more than 80% have taken up the help on offer. Only a few refused. In 27 months, we have reduced the social inequalities to 42%, which I feel is a great success and it’s because of the patient engagement.

But there are other cohorts like housebound patients that we don’t know how to approach because we’d need special services arrangements within the church, with transport and in the workforce as well. So, we are finding it is harder.

Another barrier is that the space is limited to 80 people maximum and we’re trying to figure out how to accommodate more people – perhaps a café on another day – but I’m a bit reluctant to ask the practices to provide more funding.

With the case management, we have saved about £47,000 with just 10 cases in a six-month pilot because we’ve prevented hospital admissions and things like that. But it’s difficult to quantify how many GP appointments are saved and it’s hard to say how much we are reducing workload.

We are at the very early stage of developing the veteran service, but when we have reached out, they want to talk lot about their past experiences. Obviously, I’m focusing on the health aspect and it’s about changing their attitude to seek help when they need it.  They say they don’t want to waste anybody’s time. There was one who suffers from backache – he can’t even move for a week, and then he gets better, so he doesn’t want to involve primary care or the GP. So, I’m at the very early stage of learning about how we are going to engage them.

ICB input

VV: What direction have you been given, if any, by the ICB? Does the ICB give you funding or data, for example? And do ARRS staff such as social prescribers and care coordinators enable you to do this sort of work?

SS: I was a massive sceptic of ARRS as a group because I kept thinking we need more GPs. And we do need more GPs, but my thinking about ARRS did a complete 360. ARRS has revolutionised everything.

These are incredibly important people to meet the health needs of our population. And they have massively decompressed a lot of the stress that I would have faced. As a GP, when you see poverty and all those injustices that people face on a daily basis, it grinds you down over time because you want to help but you can’t. Social prescribers are a hugely important part of helping.

There are aspects of the inclusion health work that rely on the goodwill of the GPs in a PCN because it is altruistic. It’s not going to make a fortune for them in their QOF or their enhanced commissioning framework. There’s no big moment where everybody comes down and someone takes a photo of us. It’s just decent work that’s done by good people for those who really need it.

And so, when I go to the PCN board and I ask them to fund something because it’s a good thing to do nobody ever blocks me. Everybody says, ‘You’re right, and it’s good to be reminded of what we’re actually here for and what we’re here to do’.

The other thing that’s really weird is that if you do good, it will attract funding. We don’t even ask the Council for money, but they are giving it to us because they see the work as important. So doing good will attract funding. You might need to seed fund it as a PCN at the beginning, or you may find some of your time isn’t funded at the start, but because it is good work, it will be picked up.

My thinking about ARRS did a complete 360. ARRS has revolutionised everything.

Dr Sian Stanley

ShSh: When we started out two years ago, we asked the ICB for Core20PLUS5 data at PCN level and we were told that there’s no such data available. So, we just went with what we felt was right and where we felt there was the greatest need. So, you know, rough sleepers, patients with learning difficulties on the SMI register, and young carers because we knew there were a high number of them. And we started doing targeted work.

Then, in the background, we were also working with our federation which covers all the practices within the borough to develop the Core20PLUS5 data so we now have that data. For example, we can geographically map the highest population of asthmatic children and see that, for us, it’s a heat map of where the main roads are.

PR: Our work is funded by the PCN, but that doesn’t stop me thinking about the ICB level and other PCNs.

I had an opportunity to walk in their shoes via the Southeast London Connect Leadership group. I was connected with the public commissioner of Lambert and they’re doing an amazing job for their population. They have created community hubs and community shops so these people would come and get food on prescription – fruit and veg. They work closely with supermarkets, churches, and barbershops.

That doesn’t suit my population because my population data is very different but I have taken learning points from there. I have posted to the ICB and the relevant clinical directors to see whether they can adopt this kind of approach for their cohort. And I’m more than happy to help them, as is the lead commissioner from Lambert public health. So that’s something at ICB level.

FUTURE

VV: How do you see the future of these services and this way of working when it comes to integrated neighbourhood teams? Do you feel like it’s a natural fit and you’re already doing it, though perhaps not calling it that?

ShSh: I think we’ve always worked as part of an integrated neighbourhood team. It comes back to GPs being so connected to our residents on a daily basis that you know what’s going on.

So, we already have integrated neighbourhood teams – the challenge is how we sustain them.  Sustainability is a big thing and that is where the support and recognition of the importance of this work really needs to come in.

We know from population health that wider determinants account for 80% of someone’s wellbeing and health is 20% so how can we work within these neighbourhood teams to ensure that ratio is right. We need to build on the models of care that meet the needs of our inclusion health groups.

I strongly believe that PCNs should be the core of the integrated neighbourhood team because I don’t think there’s any other organisation that understands their residents and their residents’ needs better than us.

The other thing is that this work can help bring joy back into the workplace. A lot of the health inequalities leads have said that to me. When you’re sitting in a clinic with 10-minute consultations that start with how difficult it is to get an appointment, then it feels like groundhog day.

But going to a pop-up event gives a feeling that you’re making a difference. If I think about our pop-up, there was such happiness amongst everyone there. I’ve never experienced anything like that. And I’m constantly being approached by GP trainees and medical students saying, ‘We’ve heard about X and Y pop-ups that you’ve done – how can we get involved in this work?’

The connections are the important thing here

Dr Prema Revi

PR: The cafe is an example of an integrated neighbourhood team. So, as Shankia says, we are already working closely with all the stakeholders, so it’s just about defining it as an integrated neighbourhood team.

And it’s about doing more of that sort of work. Say, for example, a menopause café where people could share and learn from each other. I think this is what we are aiming to do – we want to go further in the future.

But saying that, it depends upon the maturity of the PCN.  We are at a level of maturity with the PCN, but others may not be in the same place. I spoke to a clinical director the other day and, in his opinion, they have not done much yet. That means we are creating other health inequalities. So, how are we going to standardise the PCN?

The connections are the important thing here. I’m trying to attend the Southeast London connect leadership breakfast club as much as possible and that then connects us to other services and stakeholders, which is good. If we all come on board and have a kind of training hub for all stakeholders in one platform, then we’re not reinventing the wheel. If we can work together to co-design that, it would be really good.

At a higher level, it would be great if NHS England could give some kind of developer guidance or a framework that includes everything, such as where the clinical governance sits with a data sharing agreement and where the funding is. Then again, there’s an advantage to not having it all prescribed. Sometimes it’s good to have an open view so that you can adapt it to how you want to deliver the service. So, a loose framework, perhaps.

SS:  Those of us who are really good at our job have always been part of an integrated neighbourhood team.

We’ve always worked really well with our third-sector colleagues and local authorities because we are embedded in the communities in which we work. But the new part for me is working with our acute trusts and our biggest mental health and community trusts. It’s about now having a parity of place in that partnership.

The other positive is how this work is changing perceptions. When you look at the way primary care is portrayed in the national press, it’s soul-destroying. But our local press think we’re great and, in turn, that’s changed the vibe and the feeling towards primary care locally. We used to be pilloried. I’ve been in front of town council meetings with politicians shouting at me, but that whole ethos – the feeling and philosophy around what we’ve been doing – has completely changed, and I think that’s really important.