Coming together to improve the health and lives of the most vulnerable patients

Sevenhills+ Primary Care Network (PCN) is a group of seven GP practices which together cover around 45,000 patients in one of the most deprived and ethnically diverse parts of Sheffield. Historically, engaging with the hardest to reach parts of the community has proven difficult and, when COVID-19 became yet another barrier, the data quickly showed that even fewer patients felt confident contacting their GP with worries about their health.

Concerned the difference between the health and wellbeing of the most deprived and the most affluent in the community would increase during the pandemic, staff across the network came together to launch a new home visiting service. Unlike traditional home visiting services, which are usually reactive and deliver care based upon already identified health needs, this new service aimed to unearth the hidden health and social care needs of patients who weren’t regularly accessing medical support.

A proactive approach tailored to patients’ lifestyles

Dr Lucy Cormack, lead GP on the project and clinical director for Sevenhills+ PCN, explained the challenge in more detail:

“Health is often not the biggest worry for our patients, who have multiple social challenges. Screening uptake is low and there is a lack of engagement with long-term condition management, coupled with reduced health understanding.

“When the pandemic hit, we saw a further drop in patients coming forward to receive care and the normal reactive approach of the primary medical service was no longer adequate. So, we developed and introduced a novel way of working, to prevent the health of our most deprived and isolated patients from deteriorating even further.

“For our community, this meant a real change in the service on offer. At a time when patients were shielding or simply didn’t feel safe coming into the surgery in person, we developed a model to enable them to be seen in the safety and comfort of their own homes.”

Identifying those most at risk of poor health

Using data and local knowledge, the team identified patients who had known health conditions, but who had not been seen by a doctor for some time, as well as those who were statistically likely to be at risk of poor health or isolation based on several different factors.

Over the course of 12 weeks, 1,300 patients benefitted from the service, almost half of whom were either housebound or shielding. Whilst the service wasn’t limited to elderly patients – in fact the ages ranged from 16 to 100 – around 50% of those seen were over the age of 71.

To give some context to just how vulnerable the health of these patients was, on average, those visited were living with four long-term health conditions and taking 11 prescribed medications. Around half of the visits resulted in further action, including referrals for suspected cancers, medication changes, emergency admissions and referrals for social support to tackle isolation.

“Without the visiting service, it’s likely that the concerns expressed, and issues identified, may not have surfaced until much later, and possibly in an urgent or emergency care setting,” clarifies Dr Cormack.

Linking up services to benefit the whole family

When identifying vulnerable patients, the team came across Muhammed, a diabetic who had not had his blood sugar levels checked for a while. Before the pandemic he had been started on insulin to help manage this condition, but he had missed appointments during lockdown.

Muhammed had eight other long-term conditions and was receiving 18 repeat prescriptions. The visit was aimed at checking his medical conditions. However, whilst at the house the healthcare advisor also took the opportunity to conduct a review with Muhammed’s son.

He shared the difficulties his dad shielding during lockdown had brought and the problems they were having getting food – income was tight and they were struggling to feed themselves. Whilst waiting for Muhammed’s results, the advisor referred the family to the team’s link worker – someone who is medically trained and responsible for connecting patients to local services and groups to benefit their health and wellbeing – who made sure they were connected to the local foodbank.

“As a result of the visit, Muhammed’s medication was changed and the family is now getting regular food to eat, which means his diabetes is back under control”, says Dr Cormack. “However, if we had not proactively gone to the house, his sugar levels could have dropped dangerously low, and they may have continued to struggle to feed themselves.”

Using learnings to change outcomes for the most at-risk patients

“Whilst we expected this service to identify patients who were suffering in silence due to the fear of visiting the doctor during the pandemic, we also reconnected with many patients who had been out of touch with their surgery for much longer”, adds Dr Cormack.

“The sheer volume of need identified, and our improved understanding, led to a realisation that this is more than just the impact of COVID-19. There’s clearly an underlying issue, where those in certain sectors of the community are much less likely than others to seek to actively manage their health conditions.

“With that in mind, we’re using our learnings to explore how we can roll this service out longer term to better monitor vulnerable patients and encourage a higher uptake of regular reviews for those with long-term health conditions.”