What was the aim?
This project aimed to improve the health and wellbeing of a group of people who were obese and potentially pre-diabetic with a diagnosis of hypertension and at higher risk of developing long-term diabetes and cardiovascular disease including increased multi-morbidity. The aim was also to reduce the health inequality gap for this cohort for better health outcomes.
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 we have been able to offer them a menu of support including:
- health and wellbeing support calls
- invitation to a health check
- opportunity to see social care providers within a healthcare setting with the aim being to make every contact count.
Using linked data to understand what people need
The linked data used was general practice and data made available from the job centre and children’s centre. The number of fast-food outlets in Medway were also mapped as part of this project to highlight the impact of fast-food outlets on the health of the population.
The data showed the key attributes of people we needed to focus on were:
- people aged 20-39 years
- obese and potentially pre-diabetic with a diagnosis of hypertension
- likely to develop long-term diabetes and cardiovascular disease
- those with referrals and support from the job centre and children’s centre.
We chose a cohort of 166 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 access to support organisations.
- Increased knowledge of staff on performing brief interventions and raising health behaviour awareness.
- Increased understanding of healthy lifestyles.
- Further develop key collaborative links for housing, education, employment and children’s health.
- Further development of out-of-hospital pathways to support high-risk patients in primary care.
- Reduced difference in multimorbidity related to those in higher deprivation groups.
- Societal shift in healthy living, not just within primary care.
Who did we engage with and why?
The Action Learning Set process involved frontline health and care professionals, public health, voluntary sector organisations, healthcare system managers and commissioners. This partnership group was integral in choosing the priority group and identifying the intervention used.
How did we directly address health inequalities?
Health and social care worked together to make access to services easier, for example, social care organisations, such as the job centre, were invited to place ‘pods’ within the GP practice to allow ease of access and make every contact count.
What did we do and why?
Health and wellbeing teams and social care services were given the opportunity to set up pods in the GP practice for ease of access for the patient.
The health and wellbeing team phoned the patients to offer them individual support.
Fast-food outlets within the PCN area were mapped – this was to highlight the impact these on the health of the population.
What were patients and residents offered?
Letters were sent out to all members giving them information about the service, with an opt-out option. The health and wellbeing team then followed up the letter with a phone call, five to seven days later, to arrange an initial appointment.
Of the cohort, 61 people were highlighted for an assessment including blood pressure and weight.
How did we evaluate our impact and success and why?
Of the 29 people identified in one surgery, 16 have been contacted, four have been able to have a health and wellbeing discussion and three of them have been booked into weight management services, which is an excellent conversion rate.
What were the challenges?
- Information governance as a barrier to sharing information for indirect patient care.
- Technology – different systems collecting data but data cannot flow seamlessly for tracking the cohort.
- Resources to support GP practices, to allow headspace for doing things differently.
What were the learning points?
Having strong leadership is key to driving forward the work, including strong clinical leadership and advocacy.
A commitment from different roles and organisations to work in this new way. It took time to get the project off the ground, but it has gathered pace and momentum.
The patients signing up to the weight management intervention will be supported for the 12-week intervention and then followed up to assess the impact of the intervention.
The PHM principles of pro-active case finding high risk groups and developing targeted interventions will continue across the PCN, supported by the Public Health Team.
More co-location of health and social care services in one building to help patients access services more easily.
Share learning and model with neighbouring PCNs.