PCN clinical directors joined Pulse PCN editor Victoria Vaughan on Microsoft Teams to discuss how they are tackling health inequalities
Part Two will be published next week. The full story can be read in the online issue, on page 16
Victoria: What is your PCN doing to tackle neighbourhood health inequalities?
Dr Kieran Gilmartin, Clinical director (CD) at Fareham and Portchester PCN, Hampshire
For us, it is challenging. We’re not in one of the country’s most deprived areas. Fareham was classed as the second-best place to live.
However, we still have certain groups that are deprived. We have quite a high homeless population, and the area’s drug and alcohol unit is located where one of the practices is, so, obviously, they go hand in hand. We’ve looked at how to improve the physical and mental health of these patients, especially physical health, because obviously there is lots of evidence that their morbidity and mortality is substantially higher, by approximately 15 years.
With the aid of a home visiting team, led by one of our advanced nurse practitioners, who is our health inequalities lead, we set up a project that is a weekly service, knowing the DES [requirements]. We do a drop-in clinic there for two and a half hours, but now there’s [also] a chronic disease component, [including] those with COPD and diabetes who aren’t normally accessing the surgery.
We’re now improving the quality of their physical care as well as their mental health, and linking in with the mental health services, but specifically physical health, because that’s something they don’t engage with.
The biggest issue is, there are no extra finances for any of this. The DES highlights all of this but [has not attached] something to it. The assumption is, we use what’s already there – and what’s already there is being stretched thinner and thinner across all of the different domains. The additional roles reimbursement scheme (ARRS) was there to assist primary care but now, [those staff are]having to do all the additional stuff that’s being put on us, and [have less] ability to reduce primary care workload.
Dr Shabnam Ali, CD at Loxford PCN, Redbridge, north-east London
We’ve got a lot of issues with long-term conditions. Our team decided to take a preventive approach. It’s come about as a co-production with our local system partners, and we decided to focus on pre-diabetes.
We’ve already got a large cohort of patients with diabetes and that’s obviously causing a burden on secondary care. If we can focus on this cohort of patients to prevent them developing the disease, it may reduce the burden later on in the system.
As Kieran has mentioned, there are workforce issues. Who is going to do this work? It definitely needs doing but the bulk of it ends up falling on ARRS staff, and that pulls them out of the other work they’re meant to be doing.
Dr David Fox, CD at Hastings PCN, East Sussex
In the inequalities work for the DES, we are focusing on patients with severe mental illness. We are bringing in staff employed by the PCN to assist in getting to patients who are hard to reach or difficult to engage. We’re aiming for as high a coverage as possible because there are some people who just cannot get to practices.
Hastings has been deprived for many decades and we’re fortunate to have a lot of third-sector organisations that have the assets in their staff, whereas the practices have very few assets in the area. We are being allowed to influence the funding in order to build them up. The grand plan is to get the third sector involved in a lot of the outreach stuff and dealing with young families and children over the next couple of years. As people are saying, general practice cannot do it alone and ARRS is not enough.
Dr Dan Bunstone, CD at Warrington Innovation Network, Cheshire
We’re looking at bringing in low-friction points as access is often an issue. We’re bringing in a smart type of triage model. We’re currently creating online access points through our hubs. This will help support the inequalities work as there is availability across the day, and for those who haven’t got the internet, there are traditional access points through supported telephone triage.
The theory is that this will support increased access and availability in a self-service model, and the traditional routes will be available for those who can’t access technology easily.
We’ve also [created] health hubs. These are basically a clinical machine that the patient stands under that [measures] height, weight, BP and pulse, and feeds this information into their medical record. It’s the first stage of proactive care. We’re looking at a rollout into pharmacies and potentially a couple of supermarkets. The machine is more convenient than coming to the surgery.
Jenny Bostock, ANP and CD at Ramsgate PCN, Kent
Ramsgate has so many areas [for] population health [work]. It has been difficult to pinpoint one in particular. We were part of a pilot for population health and because we have a large elderly population
we looked at housebound diabetics, and managing them using a multidisciplinary team approach with Diabetes UK, social prescribers, clinical pharmacists, specialist nurses and healthcare assistants.
We’re now looking at our housebound patients and trying to prepare them for winter. With soaring fuel costs and food issues, we’re trying to get them to look at their housing for any draughty areas, to make sure they mitigate any problems, because we’re worried that they are going to sit in the cold and not feed themselves.
We also have a Travellers community who have recently come to the area. They’ve been here about a year, about 40 to 50 of them. Nobody would register them because they don’t have a proper address but we’ve managed to get them an address for the piece of land they are on. Another problem is that they’re illiterate mostly. Most of them don’t go to school. The children just help on the campsite. So, we’ve been going out to the campsite and getting them registered, and we’ve actually managed to do health checks on them.
The other thing we’re looking at is [access for people who are not so digitally able]. Although digital technology is going really well, we have a lot of elderly population who have landlines. They don’t have a mobile so they can’t send in photos. They can’t access the online services. We’re trying to make sure they can get access to services as well.
Dr Laura Mount, CD at Central and West Warrington PCN, Cheshire
The biggest issue for us was where to start because the data are very old and often highly inaccurate. We tried to get data from Public Health [England] and its data are often very out of date, so we’ve used various data collection tools – which also caused us many problems. So, we feel anxious entering into this work because [we’re] guessing where the priorities are in our population, [we don’t]necessarily [have] the best evidence.
We also worry if we have selected the right priority to concentrate on. Then we worry about creating postcode lotteries because there might be something brilliant going on in the next PCN. [Might] our patients benefit from that? [Might] their patients benefit from our project? In the end, we just have to pick something and go for it.
We picked diabetes and our housebound population, because we did a project with care co-ordinators where they rang the housebound diabetics. The conversations with these patients were hugely long. It was embarrassing, the level of care they’d had in the last two years. They might have been having the basics, but they had so many unmet needs because they couldn’t communicate with us – because the way of communicating with health has changed.
Victoria: Did anyone have good data on which to base their decisions?
Jenny We had quite good data. The clinical commissioning group (CCG) had someone who supported us, because for our population health project we needed to find data. The CCG analytics people were helpful as well because in general practice we don’t have that information, so it’s a really big problem to collate the information and make it into something meaningful.
David We’ve also done a population health programme and were the first in Sussex to do it. I think those that have done that first are more confident with their inequalities projects. The data support already had a good baseline for dealing with severe mental illness work. We also had [the data] cross-referenced with the acute trust as well. We probably could have got those data ourselves as practices, and I worry that trusting all those data to external parties might not help us in the future. We need our own ability to deal with the data, or a clear organisation that will do it for us.
Victoria: Would you like to see ring-fenced funding for health inequalities that is separate from the GP or PCN contract?
David When you work in a deprived area and you are short of staff, sometimes your difficulty is spending the money because you have the money but not the staff. The ARRS scheme has had some successes, but there isn’t a long-term guarantee that this funding is there forever. We need something that will be structurally there for the next 10 years that helps us all invest in the workforce and take the money.
I am seeing money available, but very little or structure to invest it in.
Also, I think the system is developing a language with Core20Plus where we’re siloing inequality for outcomes. Really we have to go back to core funding and make it [available] over a long period through the contract – a worthwhile investment to build up teams in deprived areas in primary care. Because we can’t, we haven’t got the green light to do that, we are pushing more to the third sector where it’s their role.
So, I don’t see a shortage of money, I just don’t see security to really invest [that money] and push it.
Jenny There are funding pots, but [the problem is] getting the time to know how to access the [funding]. When I worked with a CCG I was told I could access some money to help with the Travellers. But I didn’t have time to research these pots of money. If the system could tell us where they are, that would be great. They’re almost hidden and a secret.
