What was the aim?

To improve the health and well-being of a group of people aged 40 to 60 years, who are obese, suffer from anxiety and are smokers, by promoting healthier living, self-awareness and education. The end goal was to prevent the onset of associated long-term health conditions such as diabetes and cardiovascular disease.

By using the data to understand more about the group and contacting the patients individually we have been able to offer them a menu of support including: 

  • appointments with Kent Community Health NHS Foundation Trust’s One You Kent service
  • personalised plans and goals
  • signposting to other organisations. 

Garden City Clinical Director Dr David Payne said: “It is refreshing to see the mutual interest and collaborative way of working for the benefit of patients. I really enjoyed this aspect and want to develop those relationships in future population health projects. We all had a shared purpose to improve the health and wellbeing of this group of people but outside of a medical setting and away from the medical model of prescribing medication.”

Public Health Intelligence Manager Mark Chambers said: “It was great to be able to speak directly to a GP, public health and wider teams.  This integrated working and targeted intervention design has helped with the practical cohesion between data and day-to-day experiences.”

Using linked data to understand what people need

The linked data used was general practice and secondary care. The data showed the key attributes of people we needed to focus on were:

  • aged 40 to 60
  • obese
  • suffer from and being treated for anxiety
  • smokers.

We chose a cohort of 130 people with the above combined attributes the data showed were at higher risk of worsening ill health, which has a huge impact on the person and NHS resources.  

  • Increased GP staff knowledge of local groups and activities that could be shared with the cohort.
  • Improved accessibility for the patients – direct contact with a lifestyle advisor
  • Understand and value joint working between organisations.

  • Improved referrals and strategies to support mental health.
  • Increase access to and referral for weight management and stop smoking services
  • Increase self-awareness among cohort of resources they can use/access. 

  • Reduction in premature mortality and long-term conditions.
  • Reduction in pressure/demand on local health and social care services.
  • Improved mental health in the community.

Who did we engage with and why?

A wide spread of health and care professionals took part in this project: GP and practice staff, One You Kent, CCG and primary care support, medicines management and pharmacy teams, Kent County Council’s Public Health Team and Green Spaces Team. 
What did we do and why?

The primary goal was to improve wellbeing, healthy eating and to encourage physical activity in this cohort. 

Patients were identified by data analysis and screened by the practices to make sure individuals were appropriate and qualified for an intervention.

The initial contact was via letter, inviting the individual to self-refer to One You Kent. The letters were followed up with a phone call in which social prescribers and Additional Roles Reimbursement Scheme colleagues offered to help refer the patient to One You Kent. 

What were patients and residents offered?

One You Kent carried out a full assessment of each patient’s needs. Personalised plans for weight management and smoking cessation were completed for each individual; educational resources were provided which the patient could refer to in their own time.

How did we evaluate our impact and success and why?

13 referrals to One You Kent, with 11 patients attending at least one appointment. Five clients attended five appointments with a lifestyle advisor. Better evaluation is needed; counting numbers is not enough. The target was for 10 per cent of the cohort to respond to the initial contact.

What were the challenges?

  • Finding the time to assess Additional Roles Reimbursement Scheme (ARRS) roles that could support this work.
  • All colleagues need to re-think we the way we all work together – this will take time to embed.
  • Nervousness of how this can be scalable given demands and pressures – more support needed for the PCN network. 
  • Realisation needed that for some patients the time won’t be right.
  • The inability to look at the data, which was provided externally. The PCN needs to run its own data analysis next time.

What were the learning points?

  • Better evaluation and more time to do this is needed. Without a robust evaluation how do you know if the intervention is effective?
  • Need to make more use of allied health professional and ARRS roles.
  • We need to make sure Every Contact Counts and have more holistic conversations with patients to find out if they are struggling in other areas, such as housing, and how we can help.
  • Prescribing something is usually seen as good care but clinicians need to start with a patient’s heart and mind first. Need to move away from a medical model.
  • Primary care colleagues need to get to know each other better – time needed to achieve this – so we can all better understand each other skills and capacity.

Next steps

Posters and adverts to promote the One You Kent service are going to be displayed in the practice so more people can take up the offer. Build on the success of this rather than reinventing – refine the process to make it better for future cohorts.