Leading change

The Inclusion Healthcare CIC General Practice Nursing team identified a need to improve the health and wellbeing of the homeless and other marginalised groups with the support of Leicester City Clinical Commissioning Group (CCG). The nurses identified unwarranted variation with low uptake of seasonal flu vaccine amongst those patients who were rough sleepers and so were under-served and at clinical risk. They set out to address this.

Where to look

The nurse leaders identified unwarranted variation by reviewing the General Practice data on seasonal flu vaccination uptake. They were able to evidence that uptake was lower for this eligible group and there was a need for change of approach. Given the complexity of need for many of these individuals, it was important to offer wider provision of flu vaccines in a bid to increase uptake rates in this vulnerable group. This required innovative thinking and new approaches so the nurses worked closely with the rest of the multi-disciplinary team (MDT) to plan a way forward.

What to change

When looking at the available data, it was clear to the nurse leaders that fewer people who were sleeping rough on the streets were accessing GP & nurse appointments at the general practices two surgeries. This meant they were not being offered a seasonal flu vaccination and were more at risk of catching flu. It was clear to the team that many local rough sleepers were not accessing primary care health services and were more likely to attend A&E for healthcare.  Many were not registered with a GP and not aware of what primary care offered.

The nurses established a partnership approach with Leicester City Council’s (LCC) Outreach Team to determine how to best meet the health needs of these individuals   and this included being offered the seasonal flu vaccination. Through engagement and collaboration, the nurses were able to determine that whilst interested in using primary care health services, many rough sleepers found it difficult to access appointments. This impacted on their health and well-being and lessened opportunities to be offered protective interventions such as the flu vaccine.

The nurses developed an innovative approach to address this unwarranted variation and this included working outside of the typical clinical parameters for appointment times and in different locations.

How to change

The nursing manager at Inclusion Healthcare established a dedicated outreach clinic at the Anchor Centre. This was a more suitable venue offering more flexible times which had been informed by suggestions made by service users and the MDT. Together with Leicester City Council Outreach team, a clinic was arranged from 06.00 till 07.30 hours, providing a safe environment for people to use. The Outreach & Street Drinkers Forum was pivotal in encouraging homeless people to attend. They supported the distribution of leaflets and advertised the clinic.

The use of the nurse-led clinic in this setting meant service users have their breakfast, receive the flu jab should they want it and access other health and social care services in one place.

Adding value

• Better outcomes – Thirteen people attended the initial clinic with ten taking up the flu vaccine on offer. Many of this cohort had not sought medical advice for some time, which demonstrates an impact on reaching what is recognised as an under-served vulnerable population at clinical risk. Further benefits were identified anecdotally, suggesting that it provided an opportunity for general health advice and signposting to further resources in the community to support the well-being of the person. Many of the thirteen also continued to access the centre, engaging with the Outreach and LCC Housing Department to seek temporary housing, whilst also welcoming the support to access health assessment and treatment.
• Better experience – The collaborative work and the nurse-led clinic helped to advocate health promotion in a vulnerable and ‘hard to reach’ group of people. The team was able to respond more effectively to the individual as well as at population level to provide a visible nursing presence in leading and providing services. Conversational feedback at the centre has been very positive and anecdotally is making a difference locally. It is seen to have nurtured an environment that has enhanced social interactions between attendees.
• Better use of resources – Existing resources were utilised in a different way. For instance, away from a traditional general practice and into a more reachable environment and at a time that could generate the maximum opportunity to encourage and give the flu vaccination to a vulnerable patient group. This maximised the use of resources within the practice and avoiding waste through non- attendance as well as informing flu campaigns locally.

Challenges and lessons learnt for implementation

• There is a need to work collaboratively across organisations and patient groups and in having a shared goal in order to create a positive experience in the health and wellbeing for vulnerable individuals;
• A flexible approach to patient centred care is paramount;
• Due to the success of this initiative, another clinic at a different site is being established.

Find out more

For more information contact:

• Wendy Hope, Lead Nurse, Leicester City CCG, wendy.hope@leicestercityccg.nhs.uk
• Tracy Pollard, Nurse Manager, Inclusion Healthcare CIC, tracy.pollard@gp-c82670.nhs.uk