What was the aim?

To empower this group of people to make healthier lifestyle choices to prevent future worsening of conditions and ill health, which is likely to tip them into the high complexity band and impact the healthcare systems in Dover Town PCN. 

The programme aimed to support people to take personal responsibility for their health and wellbeing and introduce them to providers – such as One You and Kent County Council’s library service – to support them to make positive lifestyle changes.  

The motto of this programme of collaboration is “together everyone achieves more”.

Using a population health management approach, we have been able to improve the health and wellbeing of a high-risk group of patients identified by our linked datasets as needing more support.

By using the data to understand more about the group and contacting the patients individually, Dover Town PCN was able to offer them a menu of support including: 

  • personalised care plans
  • medicines review
  • mental health review
  • support for employment
  • opportunities to learn a new skill
  • access to a care coordinator
  • opportunities to start a physical activity.

Using linked data to understand what people need

The linked data used was general practice, patient council, community services and the voluntary sector. It showed the key attributes of people we needed to focus on were:

  • people within the highest deprivation quintile (IMD 1 and 2)
  • obese 
  • hypertension and depression
  • aged between 40 and 69.  

We chose a cohort of 131 people with the above combined attributes that the data showed were at higher risk of worsening ill health, which has a huge impact on the person and NHS resources.  

  • Increased patient participation.
  • Increased uptake of services for self-management.
  • Uptake of medication and condition reviews.
  • Increased multi-disciplinary working.

  • Better understanding of what is needed by individuals to achieve health and wellbeing goals
  • Better understanding of where gaps are and what can be put in place.

  • Losing weight.
  • Better health outcomes through better lifestyle choices.
  • Increased support through local groups.
  • New skills leading to better employment opportunities.

How did we directly address health inequalities? 

The majority of patients were from IMD 1 and 2 and the primary goals were health and physical activity, including learning a new skill. Easy to read text messages were sent to the identified patients. This text was followed by up a letter and finally a phone call if an individual had not engaged with either the text or letter. The phone call was to establish the barriers to engaging – most often it was the time that was not convenient to the individual (for example over the festive period). 

Who did we engage with and why?  

A wide spread of health and care professionals took part in training: Social prescribers, link workers, general practice, pharmacists, One You Kent, patient council, ASPIRE community health project, Take Off peer-led support group, Social Enterprise Kent, Kent Community Health NHS Foundation Trust and ICP project analysis.
We engaged with patients through the patient council representative to understand their needs, where possible. 

What did we do and why?

Patients were invited to have a discussion about their health and wellbeing and personal goals. They were encouraged to discuss issues that might be affecting their health and wellbeing including unemployment, weight and physical activity. They were introduced to organisations offering support including One You Kent, ASPIRE programme, the library service and care coordinators to find out what more support was needed. 

What were patients and residents offered?

Appointments with One You Kent – lifestyle advisors can create a personalised plan for health; provide support and signpost wider determinants of health impacting health and wellbeing – this intervention includes medicines review, baseline biometrics and support via social and voluntary organisations. 

A standard operating procedure (SOP) was created which can be completed by different staff members. A jargon-free patient-friendly, easy to read invite letter was created and sent to the cohort. 

How did we evaluate our impact and success and why?

Six patients referred to One You – three accepted. 

This is a long-term support and the programme will need to look at the data in the future to establish if attendance at the GP practice and A&E was reduced for this group of people as a result of the health and wellbeing support put in place.

What were the challenges?

IG barriers need to be tackled as a system to allow health and social care organisations to share information about population wellbeing.
An evaluation strategy was needed for effective measures – how do these interventions impact different aspects (not just healthcare) and how does the measurement translate into savings.

What were the learning points?

The intervention service had to stop and re-start because of the Covid-19 booster programme.

  • Future projects need to take into account other NHS initiatives (flu jab for example)
  • Timing is key – this project was rolled out over the festive season and therefore patient involvement was lower than it might have been at other times of the year. 
  • Working with different health and social care professionals with a common, shared purpose. Co-creation with everyone’s voice is important.
  • The clinical director does not have to lead this – representatives were from health and social care, the voluntary sector, the patient council and the library service.  
  • Need to make sure each stakeholder is ready to deliver on intervention.
  • The Patient Council’s access to grants and funding streams is useful.

Next steps

Continue meeting once a month to keep momentum going and track progress.

Look at how each practice within the PCN can interrogate their data to get a PCN theme/trend for the future.

Compare pre and post outcome measures – measure the impact of the intervention through qualitative analysis such as interviews and focus groups.

Evaluation of the process – were all the outcome measurements completed? Did participants meet all the criteria?

Plan for detailed analysis in the future with access to linked data sets.

Share learning, for example, the role of local libraries can be shared with the society of chief libraries to make sure nationally, other library authorities are receptive to being involved in similar projects.

Share the documents – letter template, the SOP, with other PCNs.

Share the learnings into the PCN DES requirement from 2022 across Kent and Medway.