Hello, and welcome to this NHS England podcast about how GPs in South London are using a Household Model to improve health outcomes. Recorded on location in Lambeth, we speak to a GP, two community workers and a researcher about the approaches they are taking to working in partnership with the Portuguese community in Stockwell.

Nadia
We are in little Portugal, as a lot of people know it for – it’s Stockwell. Very close to Vauxhall as well. It is where a lot of Portuguese speaking communities live. I am Nadia Antonio. I am project manager at Lambeth Portuguese Wellbeing Partnership. I have been working with the Household Model since 2019. I also work at a university as a senior admissions officer, but my real passion is also working in social enterprises and fighting the health inequalities within our community.

The Portuguese speaking community is quite diverse. We have Portuguese from Portugal, from Madeira and Azores. We also have Brazilians, Mozambicans, Angolans, Cape Verdeans from Guinea-Bissau and Sao Tome and Principe and other countries in Asia, such as Timor-Leste. Some from India as well. So yeah, it’s a very diverse community. And here in the heart of Stockwell, that’s where a lot of us live.

You will probably hear a lot of Portuguese with different accents, of course, but you will also see a lot of stores that sell different products from Brazil or from Portugal. We have local cafes for Portuguese, from Portugal and also a lot of Brazilian local businesses.

Vikesh
Hi, I’m Vikesh Sharma. I’m a GP in Stockwell at the Grantham practice.

I have been here as a partner now for about ten years. I’ve got real interest in health inequalities and community engagement and as part of that work I helped set up the Lambeth Portuguese Wellbeing Partnership, which is a sort of a community network around health inequalities in the local community. The context of it is we set up the Lambeth Portuguese Wellbeing Partnership, which has been running for about six, seven years now, and that was really a coming together on the ground between myself as a GP and local other community partners.

So that including sort of housing charities, educationalists, local council, but just residents and people who are quite just passionate about this. And actually what brought us together was this idea that the local Portuguese speaking population suffered a lot of inequalities and I was interested in that just from a sort of global health perspective. Why do people from different cultures and languages experience poor health outcomes?

And as I spoke to my colleagues, the local GPs who had been here a while. They told me about some of the dissatisfaction we had with how we consulted with these patients. The fact that with long term condition management like blood pressure and diabetes, we just weren’t controlling them very well. And equally we were seeing a lot of high attendance at the local A&E as well.

So there was definitely something to get involved in there. But as with a lot of these sort of issues, it’s not just a simple sort of we can solve this in general practice. A lot of it’s social determinants, right, so a lot of the community are economic migrants who have got two or three jobs on the go, don’t speak English very well.

Lots of other stuff going on behind closed doors that we’re not aware of in the system. And so really to address this problem, I need to start to speak to all these other people in the community who know about these problems. So that was the LPWP and we started lots of projects around this. So for example, we ran a breakfast clubs for children in local cafes.

We started doing sort of holistic assessments where my nurse worked with a local community developer to understand how we can support with social determinants more. And it got us thinking that are we just a network of different people on the ground who come together to deal with problems? Or actually is there something a bit more that we can do?

And what we realised was that the uniqueness of our network was we were different people with different perspectives on the aspect of inequality, and we were just looking at it from different lenses. And actually it was us coming together and looking at it and giving each other equal voice and equal perspective and say, right, how can we come together and do this differently, that was really making the difference. And so from that we got thinking that actually part of the issue is that no matter how holistic we try and be in our own day jobs, you can’t be that holistic because you’re actually you’re an expert in your field, right? So I’m a GP – I could do a diabetes review and at the end I’ll ask a few holistic questions, but do I really have the power and the know-how to deal with those issues? And likewise, if you talk to people from housing or education. So we’re kind of limited by our assessment and our expertise. So is there a way of asking questions about health and wellbeing where you’re not limited to just one expert? So rather than just asking about your diabetes or your housing or your education, ask questions about that persons immediate environment, their close social relationships. In effect their household, right? And by doing that, you’re getting a lot of information, rich information, which is asking different experts to get involved. And so we term that the housing model. And so the theory was because there’s a lot of obviously evidence around social determinants and how that affects health and health inequalities, that if you could start to work with people at this sort of household level and you improve their wellbeing and their capacity within that, then actually they would have the means to deal with the diabetes or the housing or their employment or whatever it is. But actually if you’re working out that sort of social determinant level. So that’s where the concept came from because we see different households, right?

Nadia
We see households that are just one person or we might see a family with three generations, for example, and experience with working with families or households with different dynamics is to see how everything that Vik just said, like the social contacts, the relationships, the dynamics. How the people they see themselves and how they interact with each other within their household really impacts their health and their overall wellbeing.

And what we see a lot of times is it’s a lot of times connected how they perceive what they can do about it and how much they’ve been doing about it and how much support they feel they can have. A lot of times for me, in my experience, what I see is, is that it’s almost like it’s not a revelation, maybe more like a self-awareness of how much of what they actually have around them and how they can contribute to each other’s wellbeing.

For me, at least, thinking about my culture, it’s not something that we do sitting around the table and talk about – “how you feeling?” – and having really deep conversation. So the household model gives the opportunity and the space and the time and in some what a safe environment where people can talk about that. They can reflect on their life events and map them out and find something in common where they faced something that was difficult for everyone, but probably they faced it in different ways.

And how did they support each other on that? That’s a really powerful aspect of the model. But also when they start thinking about who they are within those relationships, what role do they play on that when they start thinking about, I am so different to you, but we complement each other actually. But it will create difficulty as well.

It will create challenges within that relationship. But it’s really incredible for me to see how when they become aware of that, they’re more settled into who they are and a bit more comfortable with each other and more compassionate as well. They they start speaking to each other in a different way, no more compassionate way.

Camilla
I’m Camilla Vieira, I’ve worked in the project since February, but I’ve been working with social projects for a while.

I think when someone that is part of the family or a normal person in the community, not a doctor or not someone that’s going there with a professional. It’s like they see us just someone as they are, or with family and with problems the same as they have and they more comfortable to open up to things that they might not tell the doctor or otherwise.

And because there is someone with them, and the way we go through the tools we use with the family; sometimes people that are not so involved feel comfortable as well to start sharing. So it’s a very good opportunity for them to know each other in the household and how they can support each other. So it builds up the sense of respect and trust.

It can bring them together as a family or as a household. And to have different kind of household, especially in UK.

Nadia
And actually, like Camilla said, it’s really work that we do together, because for us to demonstrate to them, this is the exercise or this is the tool that we were using to talk about maybe difficult conversations that we might need to have, we will share a little bit about us as well. And that’s where, as Camilla was saying, people start getting a bit more comfortable because if I can show my vulnerability and be human, let’s say, then they’re more trusting and they open up in a different way that there’s no hierarchy in terms of power. It’s quite flatlined and we’re all there as people.

Dave
I’m Dave Salisbury, an independent researcher and evaluator. I’ve been working with the team on the household model for the last couple of years. That point that Nadia just made is really important. I think one thing that really comes out is that when you speak to the households or when we hear from the households through the evaluation, is that traditional health services engage with people on the terms of the service.

So if you go into the GP, to see the GP, it’s can you get the call in the morning, how long do you get stuck in the waiting list? What time are you given to get to the appointment? How do you rearrange your life to visit the service? Whereas with the household model it’s how does the household model team rearrange themselves to be on your terms?

So the household team really engage with the household on the household’s terms. And so I think that’s really important because it automatically gives some power back to the household and they meet in an environment that that household is comfortable in. So that might be in their home or it might be in a cafe or wherever it’s comfortable for them to meet.

There’s so much that’s done to give power back to the household and that’s done on their terms. And then I think the other thing that maybe wasn’t mentioned is that the team make it fun, and that’s really important because it means that people want to engage with the household model and they want to stick with it. Yes, there are challenging conversations along the way.

Yes, people do realise things about each other in their household or about themselves that they hadn’t realised before, but the team really make it fun and engaging. And they use games and activities and they plant literal seeds. They grow plants together. The household assessment is like a series of fun games to do together to find out more about each other. So I think those things are really important.

Nadia
And we bring food and a drink maybe so they don’t have to worry about if we go to their home, they don’t need to be worrying about “now I need to provide something to them”. So we’ll bring some snacks. Nothing major, but just a few snacks so the family doesn’t need to be worrying about us. It’s more about giving them the time to do it.

Vikesh
So when you’re looking at the impact of this approach, I think you can look at it in lots of different ways. Speaking as a GP, what I’m interested in is that if everything about social determinants theory that we’ve learned over the last 15, 20 years that we’ve been talking about it, is that because of all the other stuff that goes on in people’s lives, they don’t have the headspace to like actually look after themselves and engage with healthy eating or come to their checkups and stuff like that.

So what I’m really interested in is if we start to create that capacity within the household of those individuals within it, that they actually start to show indicators that they are ready to increase physical activity or quit smoking or lose weight and stuff like that. And so those are some of the things that we’re measuring through this project.

So before you’ve even seen the sort of the physical changes, it’s just that people are saying to think in a different way. And we’re definitely starting to get some of that through. And I think Dave can talk a little bit more about that. But also there’s lots of other ways and I’m sure Camilla and Nadia can talk about impact on people.

And we’ve got some great stories of how it’s changed people’s lives at a very individual level. And, we’ve touched on it, is how you approach these things, the kind of team that you need. There’s a lot of investment and energy we put in to actually what it feels like as a team, what sort of courage you need to go into these environments to talk like we do and how we support each other through that. So there’s lots of ways that you can measure this impact.

Dave
What Vik said is really important in that the way that the team work really makes a big difference to how people within the household engage with other elements of their health and the things that influence their health. One of the key things that the team does through the series of activities that they do with households and through some of the co-coaching that they do with the households, is that in the interviews for the evaluation, people have described to us that they see life in a different way.

They see new possibilities, they see what’s possible, they remember what they can do and what they’re capable of because they’re reminded by going through these activities and they understand more about who they are. They have a sort of an improved understanding of themselves and of oneself. That opens up a process for them to be able to change their behaviours or they realize their capability to change their behaviour.

They see new opportunities to do things. And that makes them feel quite motivated. What we’ve seen in our evaluation interviews so far at this interim point is that people are starting to make those life changes and starting to engage with other things beyond their health necessarily, but that may have an impact on their health too. That’s one really important thing that we see from the qualitative interviews that we do with the households when they’ve completed support.

We also do a questionnaire and a health check. And before and after people have received the intervention. The health check does some standard health indicators BMI, smoking, alcohol consumption, that kind of stuff. And we haven’t seen big changes in those yet because we’re at this interim point. But our theory is that we will see some later on down the line.

But why we are seeing changes is in the questionnaire answers. We’re using a questionnaire based on the Harvard flourishing scale and that asks some questions about whether people have purpose in their life, how they feel about their overall health and how they feel about their overall mental health. And what we’ve seen in those responses is that most of the people that we’ve surveyed are showing an improvement across those factors.

Camilla
As Dave said that is a part of the programme where we do this co-coaching series of interventions, so we can see as we go through it, how they improved or they moved some habits. So because we started by doing a plan together and then as we go through it, we can see the results of it.

And we had families, for example, that at the beginning there is one, there was one person that wouldn’t leave his room and at the end of the programme he was going to social events. Then we had one family that the child would be very closeted and he wouldn’t share what he was feeling and what he wanted for the family.

And then he started sharing things. And then we heard from the parents “Oh actually he never said something like this, he doesn’t talk about it. And it was surprising for us that he came and he sat and he started talking”. So we can see the results for them, in ourselves because we improve ourselves. We go through it as well, and learn a lot from them as well, it’s like an exchange. We try to do something with them, but we work [..]

Nadia
I remember at the time was just developing this and we were just testing the tools to see what worked, what didn’t, and just doing that process with the household. And for me it was even emotional for me at the time.

One household, a single household, this household at the time, what I was told because I didn’t work with this household before meeting them at a later stage of the process, they couldn’t leave the house. They were basically scared of a lot of things. There was a lot of anxiety. They didn’t trust doctors or anything like that.

So their wellbeing was very, very much affected. The only person that they would speak to was their son. As we did the process with them. And then when I actually met this household, they were so—how can I say—so open to the possibilities of life. It was actually for me really impactful because they were so connected with everything.

They were talking about how nature is beautiful and how they can hear the birds sing because now they go to the park. So just the way they were describing their outlook in life, it was for me very inspiring. And until today, we’re still in contact with that household and they are now helping us with events. They also share that they have just used the tube as well, where before they couldn’t use the tube, I think they were affected by something that happened in the tube a few years ago, but now they’re using it. For them, it started with the work that we did with them through the household model, and they now trust doctors a bit more—I’m not going to say it’s perfect—but they trust them. And just the fact that now they go to events and we’re there with them and they’re all the time saying, “if you need any help, I’m here for you. If you want us to support with the project”. The fact that they now have a community all around them, they have all of this fruitful life that they didn’t have before, for me, it really showed me how much of an impact we have on people’s health and wellbeing and to the community as well, because now they’re supporting the community as well.

So and now we see them in a lot of the events that we do or other organisations do in Stockwell as well, in local businesses. I often find them in cafes or something like that. To be very honest, it wouldn’t be possible four or five years ago.

Vikesh
We’ve discovered through this phase as we’ve scaled up, we’re serving 50 households in this phase, that the sort of organisational structure that we have, that’s probably our capacity at the moment.

And we’d have to look again at how we structure ourselves if we wanted to go bigger. But we passionately believe that what we’re doing is a good thing and we hope that we produce enough outcomes and indicators by the end of this that we can start to share this with other people who maybe are looking at similar things.

And so just from a very sort of systems way of thinking, like how we’ve recruited households. We’ve identified individuals where I’ve just said to my fellow colleagues, “Are there patients of Portuguese speaking that you’re struggling with?” That’s has been as open as the referral criteria is, and that’s basically meant patients who are very complex or vulnerable or have got massive social situations going on that we’re just not sure how we can help them in a ten minute appointment.

And more recently, actually, we’ve been starting to be able to run analysis on our GP appointment data where we can look at how different patient cohorts use our appointments. And what we found and this is actually quite replicable across most practices is that you’ll see that there’s a small cohort of patients that use a large number of appointments.

So for example, in Stockwell it’s roughly about 4% of our patients across the primary care network that use about 20 to 25% of our appointments every year, year in, year out. So in my practice for example, there’s about 400 patients who will be called frequent attenders or whatever. And if within that there’s about 40 Portuguese speaking patients, right?

So I’ve now got a baseline where I say, right, these are patients that we’re clearly not helping well here because they’re coming to us again and again and again. And for some reason, either we can’t help them or they feel unsatisfied with the help that they’ve got, but there’s nowhere else they can turn to. So we create this weird co-dependency where nothing really ever changes for that person and we start terming them frequent attenders in high intensity uses and stuff like that.

And actually this is a great outlet, this sort of project. So it’s this sort of learning around, okay, people that maybe current ways of working and delivering services might be struggling because we give them terms like complex, vulnerable, social determinants, frequent attenders. Actually there is a way that we can offer them a different support service. And then once you start thinking of it like that, then actually this opens up to maybe people who work in social settings, in housing settings, other health care settings.

You could technically apply this to lots of different places. So I don’t think we’re saying that we’ve solved it all, but I think we definitely would like to contribute to that sort of research and understanding around how a social determinants approach can maybe bring a better outcome for individuals that we often struggle with in services.

Dave
Like Vic said, courage takes a lot of courage as well to be in the space of vulnerability, of being aware of some traumas as well and what lines not to cross and all of that. But at the same time just being present for the communities in the way that suits them as well. It’s very important.

I think one of the other elements of courage comes from taking a view that’s outside of the system, because if Vik was looking at his own budget line, he would never have thought to start LPWP. And that often happens in the health system if we’re realistic about it. But actually the things that come up for people, are, yes, about some big problems of our age, social isolation, loneliness and sometimes feeling lonely despite being surrounded by people in your household. But there’s also lots of things around, things that would impact on some of the other budgets within the system.

So housing, for example, or people being ready to move into employment and so on. And they’re huge factors for social determinants of health. But they won’t save the GP practice any amount of money in the short term.

Nadia
For me, the thing that I sees because we developed this project aimed at the Portuguese speaking communities, then we were able to tailor some of aspects of the project to suit this community.

And although you might not be perfect, of course in all aspects we would say that people feel they are seen just because we do it in a way that they are also comfortable. So if other community groups would be able to do something similar where they can take this model and then apply it to their own communities and tailor to their own communities in a way with something that it’s important for the communities present then so great way to scale it.

Vikesh
We’ve got an interim report that’s come out, but actually what we hope is maybe early next year-ish will have a fuller report for phase four and I think that’s when we will be really much more confident in saying, okay, these are things that you might want in a team that you’re going to set up to deliver this sort of work. The approach that you want to apply when you’re doing it, how do you identify households and talk about even the household model to people? And then some of the things that you might reasonably expect from this approach, like the early indicator changes and stuff like that. So some of that stuff will hopefully hopefully be able to start publishing next year. But in the meantime, very happy for people to contact us.

Nadia
DM US, we’re on Instagram, Twitter, Facebook, so we’re present. Also, you can email hello at LPWP.org and yeah, we’re here. We’re available to anyone to want to approach us just to learn more about it.

Thanks for listening to this episode of the NHS England podcast. Our guests today were Dr Vikesh Sharma, a GP at the Grantham Practice in Stockwell, Nadia Antonio, the project manager and Camila Vieira, a project worker on the Lambeth Portuguese Wellbeing Partnership and Dave Salisbury, an independent researcher.

Links related to the project are available in the notes accompanying this podcast.

If you’ve enjoyed this podcast, please listen to further episodes, available by searching NHS England on Spotify, Apple Podcasts and SoundCloud. Also available from www.england.nhs.uk/podcasts.