Trinity Health Group Primary Care Network (THG PCN) is made up of four GP Practices – Maybush, Crofton, Warrengate and Trinity – and provides NHS health care for some of the most deprived areas in West Yorkshire.
THG PCN have been working collaboratively to address and reduce health inequalities with a big focus on case finding undiagnosed hypertension and CVD. This is in response to the support offered by NHS England as part of the Core20PLUS5 framework. The aim of this work is to improve patient access, identify missed long-term conditions and to educate and empower patients to look after their health. Our entry demonstrates the positive impact we have made on the relationships and health outcomes of ethnic minorities, by adopting the health creating practices of self-organising, listening and responding and strengths-focus.
Dr Saira Bano (f) and Dr Saadia Hayat (f), GP Partners from two of the Practices, have taken on the responsibility of Health Inequalities Lead on behalf of our PCN. Coming from an ethnic minority background, they themselves have experienced health inequalities first-hand, so this HI project is very close to their heart. Over the last 6 months, and with the support of funding from NHS England and NHS Improvements, Dr Bano, Dr Hayat and their team have been working up an exciting strategy which will build on existing work and contribute towards the HI ambitions of the 5-year NHS Long Term Plan. Our plan is to identify gaps in our service and enhance care for our local community where and when it is needed. This work will also encourage and empower patients to take greater control of their health and will help them to recognise their inner strength to remove the perceived barriers in making a positive change.
Firstly, we developed a logo and branding with the tag line ‘Everyone’s welcome here’. The purpose of this was to connect all the PCN Practices to our Health Inequalities work, but also to promote the project with frontline staff and patients. We hope that the logo will become highly visible and used on posters, leaflets and social media platforms. Staff themselves will also proudly wear a pin badge on the NHS lanyard.
Next, we developed a staff training session and workshop around patient registrations and barriers to registration, particularly for HI cohorts. Staff worked through different patient scenarios and discussed the barriers each patient may face, and the difficulties staff may have in supporting these patients to register and access primary care. Staff suggested lots of ideas to put into practice to support these patients, and this feedback informed our HI strategies.
Our next step is to develop a resource pack to support practice staff with registering new patients that may find the process of registration more challenging due to Health Inequality. This pack will contain ideas that the practice staff themselves have suggested so they can take ownership of this project.
In order to implement our strategies, we worked closely with local community groups and faith leaders to deliver a brand-new Health Inequalities (HI) service in the form of a pop-up NHS Health Check Clinic. We believe this developed a solution to the challenges that our residents face which contributes to overall poor health.
Our priorities in the first instance were to focus on the South Asian community, but we have much bigger plans in the future to widen this service to other inclusion health groups.
The pop-up clinics have since been regularly run in the local mosques and community centres and have identified cases of hypertension, diabetes and hyperlipidaemia that have not been diagnosed. This unique method of engagement with patients in the community has provided them with the confidence to look after their health and well-being which in turn has led to health improvements. By organising these pop-up clinics, we have shown to be self-organising and will continue to reach out to many different communities to improve health inequalities. As a direct result of the pop-up clinics, we are now seeing more Asian patients coming forward for routine annual health checks due to having more confidence to take better control of their health needs.
We organised ourselves by holding regular meetings with members of our Patient Participation Groups (PPG), Councillors, faith, and community leaders to listen and respond to the population health needs. For example, we attended a community group for South Asians Women and understood the difficulties they face with access to healthcare. We listened to how they do not feel supported when it comes to looking after their health. What we identified is that they need more patient education on how to access health services and the different roles available to them in primary care. We used this information to plan and deliver sessions on the different ways to access primary care, and the different roles within our multi-disciplinary team which consists of practice nurses, healthcare assistants, care co-ordinators, health and wellbeing coaches and GPs.
Our first pop up clinic was held in a local south-Asian community centre where women gather every Thursday morning. These women are mainly housebound patients, but the mosque arranges transport to bring these ladies to the centre for a social gathering and physiotherapy. Therefore, we liaised with the leaders of the mosque to help facilitate set up and deliver of the clinics. We carried out the NHS health checks and identified many elderly patients who had poorly controlled diabetes and hypertension. We managed to educate these ladies on an individual basis in their native language about the importance of medication compliance. We educated them on dietary changes that they can make within the south Asian diet to improve their health outcomes. The community was very engaging, and we will be attending further sessions to educate them on dementia awareness and weight management as these were also identified as a need for this cohort.
A case study at this clinic highlighted how we have improved other types of health outcomes, for example a 45-year-old lady who approached one of the GPs in confidence stating she needed help with her mental health. She explained the stigma in the south Asian community and how she cannot express how she feels and access support about her health. We were able to help this lady to seek the support she needs to help with this.
By adopting the features of the health creating practices, our networks and relationship with the Asian community is much improve as they have been so appreciative and grateful for this piece of work. More importantly this project has led to improved patient access and enhanced health outcomes for this group of patients.
We have accomplished an enormous amount of achievement in such a short space of time and now plan on widened our delivery of pop-up NHS health checks to other groups of patients who suffers from health inequalities, such as the travelling community for which we serve a large Gypsy and Roma site.