Healthcare and prevention through a multi-generational household approach

NHS Frimley Integrated Care Board (ICB) covers a diverse area across the three counties of Surrey, Berkshire and Hampshire. Dr Priya Kumar explains how a new multi-generational household project is supporting those at risk of health inequalities in Slough.

69% of Frimley ICB’s underserved population lives in Slough with more than 150 different languages spoken and at least a 10-year life expectancy difference from its neighbouring town. Approximately 15.1% (5,540) children live in low-income families and there is a 20-year gap with regards to the healthy years lived.

Phase 1 of the multi-generational household pilot was implemented to support the low-level herd immunity in Slough due to the low uptake of pre-school boosters. Feedback from parents suggested they were not opposed to vaccinations, but that other factors, like work schedules or caring responsibilities, were preventing them taking up the offer.

Building on the concept that 13.9% of Slough’s population live in multi-generational households, a fact that was highlighted during Covid, we decided to target multi-generational households that had outstanding immunisations. We organised home visits and used this opportunity to complete the remaining health checks for the entire family in one setting, benefiting up to three generations of residents in one go.

Using a population health approach, all the multi-generational households with outstanding pre-school boosters were identified and this data was matched to all the different health checks required to be completed within the household. This included medication reviews, QOF indicators, pre-diabetes and blood pressure checks, severe mental illness reviews, adult immunisations, breast screening, cervical and bowel screening.

Each Primary Care Network (PCN) in Slough contacted families and arranged visits for those happy to participate. We advised that all the members of the family would be reviewed in one visit, and many were arranged for after 4pm to ensure children were home from school. The hour-long visit was carried out by two staff members, and a variety of different professionals were involved, including general practitioners, nurses, healthcare assistants, pharmacists, and physician associates.

In total, over 100 households were visited over a two-week period and 68 more pre-school boosters were given at the end of the QOF year. Most of the other outstanding QOF checks were completed at the same time. NHS health checks were also provided, and family members were encouraged to collectively take up the different national cancer screening programmes.

While the aim of the pilot was to boost our childhood immunisation uptake, it soon became apparent that home visiting was also important for the 40-to-60-year age group. This is the cohort we struggle to reach in general practice because of the pressures of daily life. For example, a 39-year-old man had missed his pre-diabetic check-up for the past two and a half years and by visiting him at home, we were able to take his bloods and complete all the necessary checks, as well as discussing the importance of secondary prevention. His wife also asked if we could offer him smoking cessation advice.

Another example was a household with seven children. We completed all the immunisations required, including the 12-month immunisations and flu. The mother had missed her cervical and breast screening appointments on multiple occasions. We booked her in immediately and by supporting her with her children and the bookings, she attended both appointments and completed both her cervical and breast screening checks.

By reaching out to these residents, we were able change the narrative and empower patients to care for themselves and engage with these important preventative offers. We quickly realised we could achieve much more than we initially thought by visiting the family’s home, helping us understand the patient’s home environment and social situation. We also offered social prescriptions to 25% of the cohort, which included pre-paid certificates and highlighting the support available from voluntary organisations and through digital apps.

We are now extending this into phase two of the project and have identified 441 multi-generational households (with more than five people) who have less than 30% QOF indicators completed on 31 March 2023.

The aim of phase two is to improve prevention and health outcomes with those households not engaging through the traditional routes of primary care, which could be for a variety of reasons. This work aligns with the national Core20PLUS5 strategy and supports families to move from a reactive to proactive way of accessing healthcare. As well as supporting their health, we will be working with a variety of stakeholders such as the health visitors, social prescribers, housing support teams, and voluntary sector organisations, who will be supporting the potential social needs of the family. Packs have also been created to inform families of the support available in out of hours prior to winter as well as promoting the new Slough wellbeing website and GP websites.

My hope is that this initiative will be rolled out more widely to narrow the health inequalities gap, improve the healthy years lived, identify unknown disease and support the wider determinants of health to fundamentally change the outcomes for future generations in Slough.

Dr Priya Kumar

Dr. Priya Kumar has been a GP Partner at Kumar Medical Centre since 2013 and holds a variety of other roles. This includes being the Health Inequalities lead for Slough, Transformational Clinical Lead for Connected Care in the Frimley ICB. She has also recently been named the ‘Digital Innovator of the Year’ 2023 at the Digital HSJ awards.

Priya has been involved in transforming care across the system by working with various stakeholders including the residents, primary care, secondary care, social care, the voluntary sector, and public health. Her main passion lies in developing innovative clinical pathways by using a population health approach and applying digital solutions to improve patient outcomes whilst incorporating the residents’ views and underlying circumstances.