Yorkshire based GP partnership going above and beyond to provide care to at risk groups in their communities

Case study summary

Modality Partnership is an award-winning GP “super-partnership” made up of eight divisions of general practices across England, working together across primary care networks (PCNs). By being part of a larger group, the partnership is able to work more efficiently to provide care to the local population. This way of working has been crucial over the last two years as the country responded to the Coronavirus pandemic.

What was the aim?

Across North and West Yorkshire, GPs within the Airedale, Wharfedale and Craven (AWC) Modality GP partnership wanted to combine efforts to reach out to members of their community who were uncertain about receiving a COVID-19 vaccination, as well as those who are hesitant to access NHS services more generally.

NHS national statistics show that certain communities who do not access NHS services early on discover undiagnosed health issues later in life, so the partnership were keen to engage with these members by working in a different and proactive way, to ensure they understood the health risks and how the NHS could support them generally, as well as in response to the COVID-19 pandemic.

Bringing NHS services to the heart of the community

The partnership agreed to set up eight pilot pop-up clinics within locations that were specifically chosen to target certain health inequality groups, including people who had declined the vaccine, needed help accessing clinics, or who had not been contactable when vaccine invitations were sent out by GPs. The partnership also chose areas where language barriers were known to be an issue when accessing NHS services.

Within these pop-up clinics, people were encouraged to learn about and receive a COVID-19 vaccination or booster jab, have a health check with a member of the GP team, or speak to a professional about a particular health concern. Easily accessible sites were chosen for the pop-up clinics and each was advertised locally, as well as through regional CCG and GP practice social media accounts.

Bill Graham, Community Innovation and Development Lead for the AWC Modality GP Partnership, explained how his role is responsible for building trusted relationships between the GP partnership and neighbouring voluntary and community and social enterprise (VCSE) organisations and communities, who helped make this scale of innovation possible.

In West Yorkshire, Keighley was chosen as one area to focus efforts, due to it being included in the bottom 10% of deprivation in the UK. One site chosen was the Highfields Centre, situated in the town centre. In just one day, the GP team administered 130 vaccinations to local residents, as well as providing 80 health checks (50% of which to Asian female patients) and five baby checks on new infants.

Bill, commented: “The numbers that showed up on the day really demonstrated the need for this community to access NHS services”.

The Bracken Bank area, housing estate on the fringes of Keighley town, was also chosen to host a pop-up clinic, and a further 75 vaccinations and 20 health checks were carried out over a five hour period. Ghosia Muslim association also supported the GP partnership to run a pop-up clinic outside a local mosque, to coincide with prayer. 115 vaccinations were administered by coordinating the clinic with worship, as well as 43 health checks to members of the Muslim community.

Bill explained: “The local Imam was instrumental in promoting the pop-up clinic through announcements during prayer leading up to the event, as well as advertising the clinic through the local Mosque broadcast system”.

Creating a safe environment

Alongside the COVID and health check pop-up clinics, focused clinics were also set up at the Keighley Asian Women & Children’s Centre (KAWACC), specifically for women to come forwards for a vaccination, as well as to address any other healthcare concern. 25 health checks were carried out at this clinic, along with a further 30 COVID-19 vaccinations.

The partnership had previously worked with KAWACC earlier in the year to run the first female-only vaccination clinic, providing an environment that was culturally appropriate for some of their patients to come forward and receive their vaccine.

Bill commented: “Working with KAWACC helps us to reach patients we wouldn’t usually see in practice. Their support is crucial when engaging and building trust with this network of women”.

The GP partnership were also keen to offer the Coronavirus vaccination to residential  patients of Springfield Mill, in Keighley central, which cares for people with learning disabilities, ensuring that additional support and information was provided to patients to make their experience as pleasant as possible. The visiting GP team administered 70 COVID and flu vaccinations to residents, and performed 12 health checks, including one SMI health check. The event was very successful as both patients and their carers found the experience to be far less stressful than having to travel to a formal healthcare setting, where people can get anxious and agitated.

In total, the GP partnership administered over 650 COVID-19 vaccinations, 229 health checks and saw an approximate 550 patients over the course of their pilot one day engagement events. What worked particularly well was the ability for people to walk-in without having to book an appointment, making it convenient for those who were a bit more hesitant about receiving the vaccine.

Sabrina Brame, Lead Nurse, Airedale, said: “Most of the patients we saw had reviews due, diabetes, hypertension, vascular issues or asthma, so we were able to offer them a health check there and then. All patients were happy and engaged making the reviews more time efficient and most of all giving the patients an effective service.”

Success story

One particular lady, who attended a pop-up clinic only to accompany her mother, was extremely grateful that she decided to speak to a nurse during her visit. After receiving her diabetic review, the mother of the lady suggested that her daughter also had a health check. During her conversation with the nurse, the patient disclosed that she had been neglecting her health for some time, due to her having caring responsibilities for her son, mother, and mother-in-law.

The nurses at the clinic were able to measure her blood sugar, take a urine sample, carry out a full diabetic check and take blood samples, before referring the patient on to the duty GP list. The patient had a telephone review with a GP later that same day to look at restarting her medications. She expressed her thanks to the GP practice team and stated that if it had not been for the pop-up clinic, she would have continued to ignore her health concerns.

What were the learning points?

  • Building relationships with communities leads to trust, understanding and opportunities to succeed and make a difference to someone’s health.
  • Be data driven but be flexible in the delivery of the work. Try new ways of working.
  • In the approach let communities lead where possible – work with faith leaders, community figures to promote events such as pop up vaccine sites and health check clinics.
  • Use what we know – use population health stats and health inequalities tools like the NHS England and NHS Improvement Health Inequalities dashboard.

Next steps?

The GP partnership is already planning to roll out pop-up clinics in 2022, focusing on different health concerns including, asthmas reviews, vaccinations, cancer screening and health checks for SMI and patients with learning disabilities.